Study Guide 6

A statement or conclusion regarding the nature of a phenomenon
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Terms in this set (106)
A statement or conclusion regarding the nature of a phenomenon
Diagnosis
Cluster of signs and symptoms that indicate the presence of a particular diagnostic label.
Defining characteristics
Reasoning process
Diagnosing
Physician-prescribed therapies and treatments carried out by nurses
Dependent functions
Words that have been added to some NANDA labels to give additional meaning to the diagnostic statement.
Qualifiers
Areas of health care that are unique to nursing and separate and distinct from medical management.
Independent functions
Process of determining the relatedness of facts & determining whether any patterns are present.
Data clustering or grouping of cues
A type of potential problem that nurses manage using both independent and physician-prescribed interventions.
Collaborative problem
Nursing Outcomes
NOC
Classifications of Nursing Interventions
NIC
Causal relationship between a problem and its related or risk factorsEtiologyDiagnostic labels + client's problem statement + etiologyNursing diagnosisStandardized NANDA names for the diagnosesDiagnostic labelsNorth American Nursing Diagnosis AssociationNANDADiagnosing is the _____________phase of the nursing processsecondIn diagnosing, nurses use critical thinking skills to interpret assessment data and identify client strengths and problems. Diagnosing is a ___________step in the nursing process.pivotalProfessional nurses (registered nurses) are responsible for making ___________, even though other nursing personnel may contribute data to the process of diagnosing and may implement specified nursing care.nursing diagnosesNurses are accountable for analyzing data to determine diagnoses or ___________issuesNurses should use standardized classification ____________ when naming diagnoses.systemsThe domain of nursing diagnosis includes only those health states that nurses are educated and licensed to ____________.treat. Nurses can diagnose and treat Deficient Knowledge, Ineffective Coping, or Imbalanced Nutrition, all of which are the _____________to the medical diagnosis of diabetes mellitus.human responsesA nursing diagnosis is a judgment made only after thorough, ____________ data collection.systematicContinuum of health states described by nursing diagnoses:-deviations from health -presence of risk factors -areas of enhanced personal growth.Status of the nursing diagnosis refers to the actuality or ___________________ of the problem /syndrome or the categorization of the diagnosis as a health promotion diagnosis"potentialityKinds of diagnosis according to status:-actual -health promotion -risk -syndrome.An actual diagnosis is based on the presence of associated _________________________________.signs and symptomsA health promotion diagnosis relates to client's ____________________ to implement behaviors to improve their health condition.preparednessThe presence of risk factors indicates that a problem is likely to develop unless _____________________.nurses interveneSyndrome diagnosis is assigned by a nurse's clinical judgment to describe a _______________________ that have similar interventions.cluster of nursing diagnosesThe purpose of the diagnostic label is to direct the _________________________ and desired outcomes.formation of client goalsThe diagnostic labels may also suggest some nursing______________________________.interventionsWhen the word __________ follows a NANDA label, the nurse states the area in which the problem occursspecifyinadequate in amount, quality, or degree; not sufficient; incomplete: ____________Deficientmade worse, weakened, damaged, reduced, deteriorated: _________________Impairedlesser in size, amount, or degree: ______________________Decreasednot producing the desired effect: ______________________Ineffectiveto make vulnerable to threat: _________________________CompromisedIt is revealed in one study that nurses with the greatest amount of clinical experience possessed greater skills in ______________________determining the clients nursing diagnosis.accuratelyThe etiology component of a nursing diagnosis identifies one or more ______________________________, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care.probable causes of the health problemFor actual diagnosis, the defining characteristics are the ________________________________________.client's signs and symptoms. For risk nursing diagnosis, ____________________ are present.no subjective or objective signsThe factors that cause the client to be more vulnerable to the problem form the ________________of a risk nursing diagnosis.etiologyThe NANDA lists of defining characteristics are still being ____________________.developedMedical diagnoses refer to ____________________________________ - specific pathophysiologic responses that are fairly uniform from one client to another.disease processesNursing diagnoses describe the __________________________, a client's physical, sociocultural, psychological, spiritual responses to an illness or a health problem.human responseA client's medical diagnosis remains the same for as long as the disease process is present, but nursing diagnoses change as the client's responses ___________________________.changeIndependent nursing interventions for a collaborative problem focus mainly on __________________________ and preventing development of the potential complication.monitoring the client's conditionNursing diagnoses, by contrast, involve human responses, which _______ greatly from one person to the next.varySame set of diagnoses cannot be expected to occur with ___________________.all persons who have a particular disease or condition.Single nursing diagnosis may occur as a response to any _______________________number of diseases.The nurse uses nursing diagnoses rather than collaborative problems whenever possible, since nursing diagnoses are more _______________________________ and emphasize human responses to which the nurse can independently take action.individualized to a specific clientThe diagnostic process uses the ___________________ of analysis and synthesis.critical thinking skillsThe diagnostic process is ________________________by most nursesused continuouslyIn attaining knowledge, skill, and expertise in the practice setting, the expert nurse may seem to perform these mental processes __________________________.automaticallyThree (3) steps of the diagnostic process: _____________________ data _____________________ health problems, risks, and strengths ______________________ diagnostic statements-Analyzing data -Identifying health problems, risks, and strengths -Formulating diagnostic statementsmade worse, weakened, damaged, reduced, deteriorated: _________________ImpairedWide range of standards the nurse uses when comparing the data:-growth and development patterns -normal vital signs -laboratory valuesPoints to negative or positive _____________________.change in a client's health status or pattern.________________________ of the client population.Varies from normsIndicates a developmental ______________________delayThe nurse may cluster data inductively by combining data from different assessment areas to form a pattern; or the nurse may begin with a framework, such as ________________________________________, and organize the subjective and objective data into the appropriate categories.Gordon's functional health patternsDefining characteristics manifested by the clientSigns and symptoms (S)Factors contributing to or probable causes of the responseEtiology (E)Statement of the client's response (NANDA label)Problem (P)State in terms of a problem, not a ___________.needWord the statement so that it is ___________________________.legally advisableUse _______________________________ statementsnonjudgmentalMake sure that both elements of the statement __________________________________.do not say the same thingBe sure that cause and effect are _______________________ stated.correctlyWord the diagnosis specifically and precisely to provide ____________ for planning nursing intervention.directionUse ___________________________ rather than medical terminology to described the client's responsenursing terminologyUse nursing terminology rather than medical terminology to describe the ____________________ of the client's response.probable causeAll diagnoses are only ______________________ until they are verifiedtentativeBegin and end the diagnostic process by _________________________ and family.talking with the client andAt the end of the diagnostic process ask the client and family to ________________________ and relevance________-confirm the accuracy and -of your diagnoses.Nurses must apply knowledge from many _____________________ to recognize significant cues and patterns and generate hypotheses about the data.different areasNurses need to know the ___________________________ for vital signs.population normsNurses must determine what is __________________________________, taking into account age, physical makeup, lifestyle, culture, and the person's own perception of what is or her normal status is.usual for a particular personThe nurse should compare ______________________________ to the client's baseline when possible.actual findingsBoth novices and experienced nurses should _______________________________, whenever in doubt about a diagnosis.consult appropriate resourcesProfessional literature, nursing colleagues, and other professionals are all __________________________.appropriate resourcesThe nurse should use a _______________________________ to determine whether the client's signs and symptoms truly fit the NANDA label chosen.nursing diagnosis handbookBase diagnoses on patterns - that is, on behavior ______________________rather than on an isolated incident.over timeCritical thinking skills help the nurse to be aware of and __________________________, such as overgeneralizing, stereotyping, and making unwarranted assumptions.avoid errors in thinkingDiagnoses of the NANDA list are __________________________ but are approved for clinical use and further study.not finished productsNursing diagnosis is part of a larger, developing system of standardized ____________________________.nursing languageThe standardized system of nursing language includes classification of ___________________ and ______________________.-nursing interventions (NIC) -nursing outcomes (NOC)Mutual giving and receiving: _______________________ Sending messages: ______________________________ Establishing bonds: ______________________________ Assigning relative worth: _________________________ Selection of alternatives: _________________________ Activity: ______________________________________ of Information: ________________________ Meaning of associated with information: ____________ Subjective awareness of information: ______________-Exchanging -Communicating -Relating -Valuing -Choosing -Moving -Perceiving -Knowing -FeelingHealth Awareness, Health Management: _______________________________Health PromotionIngestion, Digestion, Absorption, Metabolism, Hydration: ____________________NutritionUrinary, Gastrointestinal, Integumentary & Pulmonary function: ____________________________Elimination/ExchangeSleep/Rest, Activity/Exercise, Energy balance, Cardiovascular-pulmonary responses, self-care: _________Activity/RestAttention, Orientation, Sensation/Perception, Cognition, Communication: _________________________Perception/CognitionSelf-concept, Self-esteem, Body Image: __________________________Self-PerceptionCaregiving Roles, Family Relationships, Role Performance: ______________________Role RelationshipSexual Identity, Sexual Function, Reproduction: ____________________________SexualityPost-trauma Responses, Coping Responses, Neuro-behavioral Stress: _________________________Coping/Stress ToleranceValues, Beliefs, Value/Belief/Action, Congruence: ____________________________Life PrinciplesInfection, Physical Injury, Violence, Environmental Hazards, Defensive Processes, Thermoregulation: ` ________________________Safety/ProtectionPhysical comfort, Environmental Comfort, Social Comfort: _____________ComfortGrowth, Development: _____________________________increase in size and change shapeThe nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement? 1. Assess the client's needs. 2. Delineate the client's problems and strengths. 3. Determine which interventions are most likely to succeed. 4. Estimate the cost of several different approaches.2. Delineate the client's problems and strengths.In the diagnostic statement "Excess Fluid Volume related to decreased venous return as manifested by lower extremity edema (swelling)," the etiology of the problem is which of the following? 1. Excess fluid volume 2. Decreased venous return 3. Edema 4. Unknown2. Decreased venous returnWhich of the following nursing diagnoses contains the proper components? 1. Risk for Caregiver Role Strain related to unpredictable illness course 2. Risk for Falls related to tendency to collapse when having difficulty breathing 3. Impaired Communication related to stroke 4. Sleep Deprivation secondary to fatigue and a noisy environment1. Risk for Caregiver Role Strain related to unpredictable illness courseOne of the primary advantages of using a three-part diagnostic statement such as the problem-etiology- 7 signs/symptoms (PES) format includes which of the following? 1. Decreases the cost of health care. 2. Improves communication between nurse and client. 3. Helps the nurse focus on health and wellness elements. 4. Standardizes organization of client data.4. Standardizes organization of client data.Steps involved in analyzing data in the diagnostic process: _______________________ against standards _______________________the cues _______________________and inconsistencies-Compare data -Cluster -Identify gaps