collaborative problem
actual or potential health problem that may occur from complications of disease, diagnostic studies, or the treatment regimen; the nurse works together with other members of the health care team toward its resolution
cue
significant information that is helpful in making decisions
data cluster
grouping of patient data or cues that points to the existence of a patient health problem
diagnosing
analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve
diagnostic error
failure to detect an actual unhealthy behavior or condition
health problem
condition related to health requiring intervention if disease or illness is to be prevented or resolved and coping and wellness are to be promoted
health promotion nursing diagnosis: behavior of an individual motivated by a personal desire to increase wel
medical diagnosis
statement about a specific disease process using terminology from a well-developed classification system accepted by the medical profession
nursing diagnosis
actual or potential health problem that an independent nursing intervention can prevent or resolve (actual problem is present; possible problem may be present, but more data are needed to confirm or disconfirm the problem; and potential problem may occur)
problem-focused nursing diagnosis
...
risk nursing diagnosis
clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation
standard
acceptable, expected level of performance established by authority, custom, or consent
syndrome
cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation
1. A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply.
a. The nurse uses the
b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or stre
2. A nurse is caring for a patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply.
a. Bronchial pneumonia
b. Impaired gas exchange
c. Ineffective air
b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infec
3. 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 confir
b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an
4. *A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagn
b. "Related to prescribed bed rest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels
5. A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient 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 H
d. Altered Health Maintenance is a nursing problem, because the diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with oth
6. The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading?
a. Compare this reading to standards.
b. Check the taxonomy of nursing diagnoses for a pertinent label.
a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards inc
7. *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." What would be the instructor's BEST response to this student's diagnosis?
a. "Was this di
a. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. A data cluster is a grouping of patient data or cues that point to the existence of a patient health problem. There may be a reason for the lack
8. *A nurse makes a clinical judgment that an African American man in a stressful job is more vulnerable to developing hypertension than a White man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis?
a. Actual
b.
b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.
9. *A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses?
1. Ineffective Coping related to inability to maintain marriage
2. Defensive Coping related to l
d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.
10. A nurse working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written as three-part nursing diagnoses?
1. Disabled Family Coping related to lack of knowledge about home car
b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement which blames home health aides for the patient's problem. Statements that may be interpreted as libel or that imply