Chapter 17 end of chapter questions

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1. A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity.The faculty member explains that the student has made a diagnostic error for which of the following reasons?
1. Incorrect clustering of data
2. Wrong diagnosis
3. Condition is a collaborative problem
4. Premature ending assessment

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2. A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes, usually twice or more." The patient had an episode of diarrhea 1 week ago. She weighs 300 lb and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.)
1. Age 42
2. Dysuria
3. Difficulty performing perineal hygiene
4. Nocturia
5. Episode of diarrhea

2. dysuria
4. Nocturia

3. Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
1. Offer frequent skin care because of Impaired Skin Integrity
2. Risk of Infection
3. Chronic Pain related to osteoarthritis
4. Activity Intolerance related to physical deconditioning
5. Lack of Knowledge related to laser surgery

2. Risk of Infection
4. Activity Intolerance related to physical deconditioning

4. Which of the following best describe a collaborative health problem? (Select all that apply.)
1. An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status
2. The language medical practitioners use to communicate a patient's health problem and associated treatments and response
3. A diagnostic label that classifies a patient's response to illness so that all nurses can be familiar with a specific patient's health care needs
4. A language used by health care providers to communicate and consider each other's unique perspective, so they can better manage the multiple factors that influence the health of individuals
5. A diagnosis that provides clear direction as to the type of nursing interventions nurses are licensed to provide independently

1. An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status
4. A language used by health care providers to communicate and consider each other's unique perspective, so they can better manage the multiple factors that influence the health of individuals

5. Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need?
1. Patient obtains social support care related to caregiver stress
2. Fear related to open-heart surgery
3. Acute Pain related to splinting of incision
4. Impaired Family Coping related to insufficient caregiver support

1. Patient obtains social support care related to caregiver stress

6. A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order.
1. Consider the context of patient's health problem and select a related factor.
2. Review assessment data, noting objective and subjective clinical information.
3. Cluster clinical data elements that form a pattern.
4. Identify appropriate assessment findings for diagnosis.
5. Identify a nursing diagnosis.

2. Review assessment data, noting objective and subjective clinical information.
3. Cluster clinical data elements that form a pattern.
5. Identify a nursing diagnosis.
1. Consider the context of patient's health problem and select a related factor.
4. Identify appropriate assessment findings for diagnosis.

7. A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced movement of lower leg, reduced range of motion in left knee, and difficulty turning in bed without assistance. This data set is an example of:
1. Collaborative data set.
2. Diagnostic label.
3. Related factors.
4. Data cluster.

4. Data cluster.

8. A nurse reviews data gathered regarding a patient's response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxietywith those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in? (Select all that apply.)
1. Data collection
2. Data clustering
3. Data interpretation
4. Making a diagnostic statement
5. Goal setting

2. Data clustering
3. Data interpretation
4. Making a diagnostic statement

9. A nursing assessment reveals a patient in the home setting who has reduced mobility following recovery from a stroke. The patient has weakness in the left leg and arm. The patient has a walker, which he has never used before, and his wife tells the nurse that he is unsteady in using the walker. The patient fell while in the hospital. The physical therapist came to the home, but the wife tells the nurse, "We are not sure how to get my husband upstairs. The therapist explained how to use the walker, but we have questions." The nurse developed the following concept map. Place the links between the nursing diagnoses in the correct direction.

Arrows should go directly from Impaired Mobility to Risk for Fall. The patient's weakness after a stroke places him at risk for falling in the home. Arrows should go directly from Lack of Knowledge to Risk for Fall. The patient's uncertainty on how to use the walker and how to ascend floors adds risk for falling. Arrows should go directly from Lack of Knowledge to Impaired Mobility because having uncertainty on how to use a walker might further impair the patient's ability to ambulate.

Image: 9. A nursing assessment reveals a patient in the home setting who has reduced mobility following recovery from a stroke. The patient has weakness in the left leg and arm. The patient has a walker, which he has never used before, and his wife tells the nurse that he is unsteady in using the walker. The patient fell while in the hospital. The physical therapist came to the home, but the wife tells the nurse, "We are not sure how to get my husband upstairs. The therapist explained how to use the walker, but we have questions." The nurse developed the following concept map. Place the links between the nursing diagnoses in the correct direction.

10. Fill in the Blank:
A(n)__________________________ diagnosis is one that applies when there is an increased potential or vulnerability for a patient to develop a problem.

risk diagnosis

1. A nurse identified that a patient has difficulty turning in bed, moves slowly when assisted into a chair, and expresses having breathlessness after walking to the bathroom and back. The patient has been in the hospital for over 4 days. Write a three-part nursing diagnostic statement using the PES format

An appropriate PES diagnostic statement would be: Impaired physical mobility related to deconditioning evidenced by difficulty turning in bed and breathlessness after walking.

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2. Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.)
1 Impaired Skin Integrity related to physical immobility
2 Fatigue related to heart disease
3 Nausea related to gastric distention
4 Need for improved Oral Mucosa Integrity related to inflamed mucosa
5 Risk for Infection related to surgery

1 Impaired Skin Integrity related to physical immobility
3 Nausea related to gastric distention

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3. A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.)
1. Data collection.
2. Data clustering.
3. Data interpretation.
4. Making a diagnostic statement.
5. Goal setting.

1. Data collection.
3. Data interpretation.

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4. The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n):
1. Risk nursing diagnosis.
2. Problem-focused nursing diagnosis.
3. Health promotion nursing diagnosis.
4. Wellness nursing diagnosis.

2. Problem-focused nursing diagnosis.

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5. A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of:
1. Collaborative data set.
2. Diagnostic label
.3. Related factors
.4. Data cluster.

.4. Data cluster.

Chapter 17 end of chapter questions

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