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NCM 103 - MIDTERMS > Nursing Process: Diagnosis > Flashcards

Nursing Process: Diagnosis Flashcards

1
Q

Second step of the Nursing Process

A

Diagnosis

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2
Q

Interpret & analyze clustered data.

A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION

A

B. DIAGNOSIS

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3
Q

Identify client’s problem and strengths.

A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION

A

B. DIAGNOSIS

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3
Q

Formulate Nursing Diagnosis

A

NANDA — North American Nursing Diagnosis Association

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4
Q

NANDA means

A

North American Nursing Diagnosis Association

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5
Q

The conclusion you make during this phase affect the entire plan of care.

A

Diagnosis

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6
Q

Made by a physician refers to a pathophysiologic response that are fairly uniform from one client to another.

A

Medical Diagnosis

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7
Q

TRUE OR FALSE?

Nursing diagnosis is directive of nursing intervention.

A

TRUE

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8
Q

TRUE OR FALSE?

Nursing diagnosis is an actual, not a potential

A

FALSE

Nursing diagnosis is either actual or potential

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9
Q

TRUE OR FALSE?

Nursing diagnosis is not only within the scope of nursing practice

A

FALSE

Within the scope of nursing practice

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10
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

MAIN FOCUS: The impact of disease, trauma or life changes upon patient and families (human responses)

A

NURSING DIAGNOSIS

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11
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

MAIN FOCUS: Disease, trauma, and pathophysiology

A

MEDICAL DIAGNOSIS

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12
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

MAIN FOCUS: Problems with functioning independently (ADL)

A

NURSING DIAGNOSIS

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13
Q

NURSING DIAGNOSIS OR MEDICAL
DIAGNOSIS?

MAIN FOCUS: Quality of life issues (pain, ability to do desired activities, but to a lesser extent than nursing – they often refer this problem to other disciplines.

A

MEDICAL DIAGNOSIS

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13
Q

NURSING DIAGNOSIS OR MEDICAL
DIAGNOSIS?

MAIN FOCUS: Quality of life issues (pain, ability to do desired activities)

A

NURSING DIAGNOSIS

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14
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

MAIN FOCUS: Allows opportunity to ramble and get off track.

A

MEDICAL DIAGNOSIS

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15
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

PRIMARY MANAGER OF THE PROBLEM: They may use other resources such as physical therapy or physician expertise, but the nurse accepts primary responsibility for monitoring status and allocating resources.

A

NURSING DIAGNOSIS

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16
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

PRIMARY MANAGER OF THE PROBLEM: Physician or Advanced Practice Nurse

A

MEDICAL DIAGNOSIS

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17
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

DEFINITIVE DIAGNOSIS: Authority to diagnose is within the nursing domain

A

NURSING DIAGNOSIS

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18
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

DEFINITIVE DIAGNOSIS: Nursing is required to seek physician or APN diagnosis

A

MEDICAL DIAGNOSIS

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19
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Identification of the factors, anticipating complications

A

NURSING DIAGNOSIS

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20
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Monitoring to detect and report early signs and symptoms or potential complications or change in status.

A

NURSING DIAGNOSIS

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21
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Initiating actions within the nursing domain to prevent or minimize the problems and their potential complications.

A

NURSING DIAGNOSIS

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22
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Identification of signs, symptoms, and risk factors

A

MEDICAL DIAGNOSIS

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23
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Early detection of actual or potential problem.

A

MEDICAL DIAGNOSIS

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24
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Initiation of a comprehensive plan to prevent, correct, or control the problems (nurse is the primary manager of the problems)

A

MEDICAL DIAGNOSIS

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25
Q

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Implementing medical orders (physician or APN is primary manager of the problem.

A

NURSING DIAGNOSIS

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26
Q

Focuses on the physical, psychosocial & spiritual needs of the client

A

NURSING DIAGNOSIS

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27
Q

Address actual existing problems

A

MEDICAL DIAGNOSIS

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28
Q

Focuses on the physical condition of the client

A

MEDICAL DIAGNOSIS

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29
Q

Address actual & potential problems

A

NURSING DIAGNOSIS

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30
Q

Not validate with the client

A

MEDICAL DIAGNOSIS

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31
Q

Validate with the client, if possible

A

NURSING DIAGNOSIS

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32
Q

Uses individualized goals & interventions

A

NURSING DIAGNOSIS

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33
Q

Uses standardized goals & treatments

A

MEDICAL DIAGNOSIS

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34
Q

May not be resolve

A

MEDICAL DIAGNOSIS

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34
Q

Usually resolvable

A

NURSING DIAGNOSIS

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35
Q

Within the scope of nursing practice

A

NURSING DIAGNOSIS

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36
Q

Within the scope of medical practice

A

MEDICAL DIAGNOSIS

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37
Q

Identify responses to health and illness

A

NURSING DIAGNOSIS

38
Q

Focuses on curing pathology

A

MEDICAL DIAGNOSIS

39
Q

Can change from day to day

A

NURSING DIAGNOSIS

40
Q

Stays the same as long as the disease is present

A

MEDICAL DIAGNOSIS

41
Q

TYPES OF DIAGNOSIS

A

Actual
Risk
Wellness/ Health Promotion
Possible
Syndrome

42
Q

A type of nursing diagnosis that is present or existing problem that may or may not necessitate immediate concern.

A

Actual Nursing Diagnosis

43
Q

PES Approach

A

P – Problem
E – Etiology
S – signs and symptoms

44
Q

A type of nursing diagnosis that relates to clients’ preparedness to implement behaviors to improve their health condition

A

Health Promotion Diagnosis

45
Q

A type of nursing diagnosis that is client problem that is present at the time of the nursing assessment.

A

Actual Nursing Diagnosis

46
Q

PRS Approach

A

P – Problem
R – Risk Factors
S – signs and symptoms

47
Q

A type of nursing diagnosis that is assigned by a nurse’s clinical judgement to describe a cluster of nursing diagnoses that have similar interventions.

A

Syndrome Diagnosis

48
Q

Domains of NANDA

A

Domain 1: Health Promotion.
Domain 2: Nutrition.
Domain 3: Elimination and exchange.
Domain 4: Activity/rest.
Domain 5: Perception/cognition.
Domain 6: Self-perception.
Domain 7: Role Relationships
Domain 8: Sexuality
Domain 9: Coping/Stress Tolerance
Domain 10: Life Principles
Domain 11: Safety/Protection
Domain 12: Comfort
Domain 13: Growth/Development

49
Q

Domain 2 Classes

A

Class 1: INGESTION
* Insufficient breast milk
* Ineffective breastfeeding
* Imbalanced nutrition: less than body requirements
Class 2: DIGESTION
Class 3: ABSORPTION
Class 4: METABOLISM
Class 5: HYDRATION

50
Q

3 components of NANDA

A

o The problem and its definition
o The etiology
o The Defining Characteristics

51
Q

The standardized NANDA names for the diagnoses are called

A

Diagnostic labels

52
Q

relationship) between a problem and its related or risk factors is called

A

Nursing Diagnosis

53
Q

Are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement,

A

Qualifiers

53
Q

Inadequate in amount, quality, or degree; not sufficient;

A

Deficient

53
Q

Made worse, weakened, damage, reduced, deteriorated

A

Impaired

54
Q

Lesser in size, amount, or degree

A

Decrease

55
Q

FUNDAMENTAL PRINCIPLES AND RULES OF DIAGNOSTIC REASONING

A

Know your qualifications and limitations.

Keep an open mind.

Making diagnoses involve comparing your patient’s cues (signs and symptoms) with the “textbook picture” of the diagnoses you suspect.

Name problems by using the labels that most closely match assessment cues.

When you suspect a specific problem,
look for other signs, symptoms, and risk factors commonly associated with the problem.

Include problems from patient’s
perspective

Patients often present complaining of two or more related problems.

56
Q

TRUE OR FALSE?

People have the right to be assessed by a qualified health care professional.

A

TRUE

57
Q

TRUE OR FALSE?

Although you may feel that you have the knowledge to do an assessment and diagnose the problems, you should not determine (for your patient and your own legal protection) whether you have the authority to do so.

A

FALSE

Although you may feel that you have the knowledge to do an assessment and diagnose the problems, you must determine (for your patient and your own legal protection) whether you have the authority to do so.

58
Q

TRUE OR FALSE?

Keeping an open mind prevents you from seeing problems from a broad perspective, a common critical thinking error.

A

FALSE

Prevents you from seeing problems from a narrow perspective, a common critical thinking error.

59
Q

TRUE OR FALSE?

You make a definitive diagnosis, when your patient’s data closely match the “textbook picture” of the diagnosis you suspect.

A

TRUE

60
Q

TRUE OR FALSE?

Diagnosis is based on recognizing when patient cues match the signs and symptoms or defining characteristics of a specific diagnosis.

A

TRUE

61
Q

TRUE OR FALSE?

“More than one cue, more likely its
TRUE. More than one source, more
likely of course.”

A

TRUE

62
Q

TRUE OR FALSE?

Patients know themselves best and must not be included in the diagnostic process.

A

FALSE

Patients know themselves best and must be included in the diagnostic process.

63
Q

TRUE OR FALSE?

Often one problem creates another.

A

TRUE

64
Q

Diagnostic process involves

A

critical thinking skills of analysis and synthesis.

65
Q

The separation into components, that is, the breaking down of the whole into its parts

A

Analysis

66
Q

The putting together of parts into the whole

A

Synthesis

67
Q

Analysis is also what type of reasoning

A

Deductive Reasoning

68
Q

Synthesis is also what type of reasoning?

A

Inductive Reasoning

69
Q

ANALYZING DATA includes

A
  1. Compare data against standards (identify significant cues).
  2. Cluster the cues (generate tentative hypotheses).
  3. Identify gaps and inconsistencies.
69
Q

STEPS ON HOW TO MAKE DEFINITIVE
DIAGNOSIS

A
  1. Analyzing data
  2. Identifying health problems, risks, and strengths
  3. Formulating diagnostic statements
69
Q

A cue is considered significant if it does any of the following:

A
  • Point to negative or positive change in a client’s health status or pattern.
  • Varies from norms of the client population.
  • Indicates a developmental delay.
70
Q

TRUE OR FALSE?

Sources of conflicting data include measurement error, expectations and inconsistent or unreliable reports.

A

TRUE

71
Q

IDENTIFYING HEALTH PROBLEMS,
RISKS, AND STRENGTHS

A
  • Determining problems and risk
  • Determining strengths
72
Q

After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnoses.

A

Determining problems and risk

73
Q

Establish the client’s strengths, resources, and abilities to cope

A

Determining strengths

74
Q

Which one is correct?

  1. Needs suctioning because she has many secretions.
  2. High Risk for Aspiration related to
    excessive or secretions.
A

Option 2

Write the diagnosis in terms of the person’s response rather than nursing need.

75
Q

Which one is correct?

  1. Altered Sexuality Patterns related to change in body image
  2. Altered Sexuality Patterns caused by change in body image.
A

Option 1

Use “RELATED TO” rather than “DUE TO” or “CAUSED BY” to connect the two parts of the statement.

76
Q

Which one is correct?

  1. High Risk for trauma related to inadequately maintained skin traction.
  2. High Risk for trauma related to hazards of skin traction.
A

Option 1

Write the diagnosis in LEGALLY advisable terms.

77
Q

Which one is correct?

  1. Impaired social interaction related to
    confinement to home.
  2. Confinement to home related to impaired social interaction.
A

Option 1

Avoid reversing the parts.

77
Q

Which one is correct?

  1. Altered Parenting related to poor bonding with child.
  2. Altered Parenting related to prolonged separation from child.
A

Option 2

Write the diagnosis WITHOUT value judgements.

78
Q

Which one is correct?

  1. Withdrawn behavior related to inability to engage in satisfying personal relationships.
  2. Social isolation related to inability to engage in satisfying personal relationships.
A

Option 1

Avoid including signs & symptoms of illness in the first part of the statement.

79
Q

Which one is correct?

  1. Stress Incontinence related to impaired muscle tone of the urinary bladder.
  2. Stress incontinence related to inability to control urine.
A

Option 2

Be sure that the two parts of the diagnosis do not mean the same thing.

80
Q

Which one is correct?

  1. Knowledge Deficit (Prenatal Diet)
  2. Knowledge Deficit (Pregnancy)
A

Option 1

Express the problems and related factors in terms that can be changed.

81
Q

Which one is correct?

  1. High Risk for trauma related to dizziness.
  2. Fatigue related to dizziness.
A

Option 1

State the diagnosis CLEARLY & CONCISELY.

82
Q

The client’s response to a problem

A

Problem Statement

83
Q

What’s causing/ contributing to the client’s problem

A

Etiology

84
Q

What’s the evidence of the problem

A

Defining Characteristics

85
Q

GUIDELINE FOR WRITING A NURSING
DIAGNOSTIC STATEMENT

A
  1. State in terms of problem, not a need or intervention
  2. Non-self-Incriminating
  3. Use non-judgmental statement
  4. Both elements of the statement do not say the same thing
  5. Cause and effect are correctly stated
  6. Use nursing terminology rather than medical terminology to describe the client’s response.
86
Q

Which one is wrong and which one is correct?

Fluid replacement r/t fever
Deficient fluid volume r/t fever

A

Wrong: Fluid replacement r/t fever

Correct: Deficient fluid volume r/t fever

86
Q

Which one is wrong and which one is correct?

Impaired skin integrity r/t improper positioning

Impaired skin integrity r/t immobility

A

Wrong: Impaired skin integrity r/t improper positioning

Correct: Impaired skin integrity r/t immobility

87
Q

Which one is wrong and which one is correct?

Spiritual distress r/t strict rules necessity church attendance

Spiritual distress r/t inability to attend church services secondary to immobility.

A

Wrong: Spiritual distress r/t strict rules necessity church attendance

Correct: spiritual distress r/t inability to attend church services secondary to immobility.

88
Q

Which one is wrong and which one is correct?

Risk for ineffective airway clearance r/t pneumonia.

Risk for ineffective airway clearance r/t to accumulation of secretions in lungs.

A

Wrong: Risk for ineffective airway clearance r/t pneumonia.

Correct: Risk for ineffective airway clearance r/t to accumulation of secretions in lungs.

88
Q

Which one is wrong and which one is correct?

Impaired skin integrity r/t ulceration of sacral area

Risk for impaired skin integrity r/t immobility

A

Wrong: Impaired skin integrity r/t ulceration of sacral area

Correct: Risk for impaired skin integrity r/t immobility

88
Q

Which one is wrong and which one is correct?

Pain related to serve headache

Severe headache r/t fear of addiction to narcotics

A

Wrong: Pain related to serve headache

Correct: severe headache r/t fear of addiction to narcotics

NCM 103 - MIDTERMS (7 decks)

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