Chapter 12: Diagnosing

A registered nurse is writing a diagnosis for a 28-year old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process?

A nurse is caring for an older adult patient who presents with labored respirations, productive cough and fever. What would be appropriate nursing diagnoses for this patient?

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem?

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phase represents the etiology of this diagnostic statemetn?

A nurse is counseling a 60 year old female patient who refuses to look at or care for a new colostomy. She tells the nurse "I don't care what I look like anymore. I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem?

To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation". Which of the following comments is the nurse most likely to hear from the instructor?

A nurse makes a clinical judgement that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or similar situation. The nurse has formulated what type of nursing diagnoses?

A nurse is writing nursing diagnosis for patients in a psychiatrist's office. Which nursing diagnosis are correctly written as two-part nursing diagnoses?

A nurse writes nursing diagnoses for patients and their families visiting a community health clinic. Which nursing diagnoses are correctly written as 3 part nursing diagnoses?

Nursing [blank_start]diagnosis[blank_end] provide the basis for selecting nursing [blank_start]interventions[blank_end] that will achieve valued patient outcomes.

The purpose of diagnosis is to clarify the exact nature of the problems and risks that must be addressed to achieve the overall expected outcomes of care.

Nursing diagnoses are written to describe patient problems or issues that nurses can treat copendently.

[blank_start]Significant[blank_end] [blank_start]data[blank_end] ([blank_start]cue[blank_end]) should raise a red flag for the nurse, who then looks for [blank_start]patterns[blank_end] or [blank_start]clusters[blank_end] of data that signal an actual or possible nursing diagnosis.

Nursing diagnosis should always be derived from [blank_start]clusters of significant data[blank_end] rather than from [blank_start]one single cue[blank_end].

[blank_start]Label[blank_end]: Imbalanced Nutrition: More Than Body Requirements [blank_start]Definition[blank_end]: Intake of nutrients that exceeds metabolic needs [blank_start]Defining Characteristics[blank_end]: Concentrating food intake at the end of day Sedentary activity level [blank_start]Related Factors[blank_end]: Excessive intake in relation to metabolic need Excessive intake in relation to physical activity

Most nursing diagnoses are written either as a 2-part statement listing the patient's problem and it cause or 3-part statement that also includes the problem's defining characteristics.

Problem: [blank_start]Bathing/Hygiene Self-Care Deficit[blank_end] linked by: [blank_start]related to[blank_end] Etiology: [blank_start]Fear of falling in the tub and obesity[blank_end] linked by: [blank_start]as evidenced by[blank_end] Defining: [blank_start]Strong body and urine odor, unclean hair[blank_end]: [blank_start]"I'm afraid I'll fall in the tub"[blank_end]

After a tentative nursing diagnosis is formulated, it should not be validated, as it was validated during the assessment.

Patients who are able to participate in decision making should be encouraged to validate the diagnosis.

The nursing diagnosis taxonomy provides nursing with...

A client is brought to the emergency in an unconscious condition, accompanied by his son. The client is having respiratory arrest and is put on a ventilator. What is the most appropriate nursing diagnosis for this client?

Which of the following is classified as a nursing diagnosis?

Which of the following nursing diagnoses has the highest priority when caring for an older client with Alzheimer's disease?

What information provides the nurse with accuracy when developing a nurse diagnosis?

The act of analyzing and synthesizing cues requires what?

After educating a group of students on the different types of nursing diagnosis, the instructor determines that the education was successful when the students identify wellness diagnoses statements as consisting of how many parts?

What activity does the nurse perform during the diagnosing stage?

The nurse is examining the assessment data of a client and diagnoses a problem of impaired tissue perfusion based on the following assessment data cues: left foot cool/pale w/capillary refill > 3 seconds, diminished dorsalis pedis posterior tibial pulses, client complaint of cramping pain in left foot. The nurse is doing what?

After assessing a client, a nurse identifies the nursing diagnosis: Ineffective Airway Clearance related to thick tracheobronchial secretions. The nurse would classify this nursing diagnosis as which type?

Which of the following best defines nursing diagnoses?

Nursing diagnosis that require physician-prescribed and nurse-prescribed actions would be what type of problems?

In the development of a nursing diagnosis for a client who has cachexia and decreased weight, what would be an appropriate nursing diagnosis?

The process of nursing diagnoses carries legal implications for nurses. Which of the following legal responsibilities exists for a nurse who has documented a nursing diagnosis related to a client's kidney failure?

Which of the following statements appropriately identifies an at-risk nursing diagnosis for a woman 78 years of age who is confined to bed?

A client with HIV has been admitted to a health care facility. Which of the following nursing diagnosis should be of the highest priority, keeping in mind the client's condition?

What is the purpose of establishing a nursing diagnosis?

The nurse formulates the following nursing diagnosis: Disturbed body image related to decreased ability to cope surgical removal of right breast. AEB client refuses to look at surgical site and client statement "I"m ugly. My husband will no longer find me desirable." Which of the following is the etiology?

A male client age 67 years has right lower quadrant pain that has been diagnosed as appendicitis and subsequently treated by open appendectomy. How should the nurse document a potential complication related to this patient's diagnosis treatment?

A nurse who is caring for a client admitted to the nursing unit with acute abdominal pain formulates the care plan for the client. Which of the following nursing diagnosis is the highest priority for this client?

A nurse is caring for a client admitted with dehydration after completing a triathlon on a hot dry climate. The nurse identifies an appropriate nursing diagnosis for this client as: Deficient fluid volume related to insufficient fluid intake as evidenced by blood pressure 84/46, heart rate 145, concentrated urine, and client stating that he drank 200 mL of water during the 4 hour event. Identify the problem statement in the nursing diagnosis.

A nurse is justified in independently identifying and documenting which of the following diagnoses related to impaired elimination?

Which of the following errors has the nurse made in formulating the following nursing diagnosis: Prolonged immobility related to impaired skin integrity AEB one inch diameter open area on right buttocks surrounded by one inch margin of redness; wound surface clean and beefy red; no drainage or foul odor detected

A nurse is caring for a client diagnosed with arthritis. The client is experiencing pain that is interfering w/her ability to ambulate. The nurse accurately documents which of the following as a nursing diagnosis in the client's records?