nursing

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? Select all that apply.
The nurse uses the nursing interview to collect patient data.
The nurse analyzes data collected in the nursing assessment.
The nurse develops a care plan for the patient.
The nurse points out the patient’s strengths.
The nurse assesses the patient’s mental status.
The nurse identifies community resources to help The nurse analyzes data collected in the nursing assessment.
The nurse points out the patient’s strengths.
The nurse identifies community resources to help

Rationale: 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 strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of 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? Select all that apply.
Bronchial pneumonia
Impaired gas exchange
Ineffective airway clearance
Potential complication: sepsis
Infection related to pneumonia
Risk for septic shock Impaired gas exchange
Ineffective airway clearance
Risk for septic shock

Rationale: 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 infection are medical diagnoses, and “potential complication: sepsis” is a collaborative problem.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?
No problem
Possible problem
Actual nursing diagnosis
Clinical problem other than nursing diagnosis Possible problem

Rationale: 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 actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.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 phrase represents the etiology of this diagnostic statement?
Risk for Impaired Skin Integrity
Related to prescribed bedrest
As evidenced by
As evidenced by reddened areas of skin on the heels and back Related to prescribed bedrest

Rationale: “Related to prescribed bedrest” 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 and back” are the defining characteristics of the problem.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?
Collaborative problem
Interdisciplinary problem
Medical problem
Nursing problem Nursing problem

Rationale: Nursing Problem, because it 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 other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to:
Compare this reading to standards.
Check the taxonomy of nursing diagnoses for a pertinent label.
Check a medical text for the signs and symptoms of high blood pressure.
Consult with colleagues. Compare this reading to standards.

Rationale: 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 include normative values for the patient’s age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.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?
“Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue.”
“Job well done . . . you’ve identified this problem early and we can manage it before it becomes more acute.”
“Is this an actual or a possible diagnosis?”
“This is a medical, not a nursing problem.” “Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue.”

Rationale: A data cluster is a grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. There may be a reason for the lack of a bowel movement for 2 days, or it might be this individual’s normal pattern.A nurse makes a clinical judgment 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 diagnosis?
Actual
Risk
Possible
Wellness Risk

Rationale: 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.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 loss of job and economic security
(3) Altered Thought Processes related to panic state
(4) Decisional Conflict related to placement of parent in a long-term care facility
Answers:
(1) and (2)
(3) and (4)
(1), (2), and (3)
All of the above All of the above

Rationale: 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.A nurse writes nursing diagnoses for patients and their families visiting a community health clinic. Which nursing diagnoses are correctly written as three-part nursing diagnoses?
(1) Disabled Family Coping related to lack of knowledge about home care of child on ventilator
(2) Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-pound weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height weight charts
(3) Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments “I cannot do this,” “I know I’ll harm her because I’m not a nurse,” and “I can’t do medical things”
(4) Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as “How could God do this to me?,” “I don’t deserve this,” “I don’t understand. I’ve tried to live my life well,” and “How could God make me suffer this way?”
(5) Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver’s loss of weight and clinical depression
Answers:
(1) and (3)
(2) and (4)
(1), (2), and (3)
All of the above (2) and (4)

Rationale: (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.