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Chapter 017

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 17: Nursing Diagnosis MULTIPLE CHOICE 1. The nurse uses nursing diagnoses after completion of the client assessment, because they: 1. Are required for accreditation purposes 2. Identify the domain and focus of nursing 3. Assist the nurse to distinguish medical from nursing problems 4. Make all client problems become more quickly and easily resolved ANS: 2 After completing the client assessment, the nurse develops nursing diag
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 17: Nursing iagnosis! #T$P#E C%$CE 1.The nurse uses nursing diagnoses after completion of the client assessment, because they:1.Are required for accreditation purposes2.Identify the domain and focus of nursing3.Assist the nurse to distinguish medical from nursing problems4.a!e all client problems become more quic!ly and easily resol edA#$:2After completing the client assessment, the nurse de elops nursing diagnoses based on the data obtained. #ursing diagnoses distinguish the nurse%s role from that of the  physician, and nursing diagnoses help nurses to focus on the role of nursing in client care.Although most state nurse practice acts include nursing diagnosis as part of the domain of nursing practice, nursing diagnoses are not required for accreditation purposes. edical  problems are identified &ith medical diagnostic statements to treat a disease condition.  #ursing diagnoses describe the client%s actual or potential response to a health problem that the nurse is licensed and competent to treat. #ursing diagnoses distinguish the nurse%s role from that of the physician. #ursing diagnoses may facilitate communication among health professionals, but they do not necessarily allo& all client problems to  become more quic!ly and easily resol ed.'I(:A)*(:24+-:/no&ledgeT0:#ursing 0rocess: 'iagnosis$:#* test plan designation: 5ealth 0romotion and aintenance2.A 637year7old client is seen at the clinic for a yearly physical e8amination. In e aluating the client%s &eight, the nurse also considers the age and height. This is an e8ample of:1.'efining the client problem2.)ecogni9ing gaps in data assessment3.omparing data &ith normal health patterns4.'ra&ing conclusions about the client%s responseA#$:3The nurse uses scientific !no&ledge and e8perience to analy9e and interpret data collected about the client. This includes comparing the data &ith norms. The nurse is comparing data to determine if there is a problem. A problem has not yet been identified. The nurse is not recogni9ing gaps in data assessment. An e8ample of a gap in data assessment &ould be if the client%s &eight had not been measured. The nurse has not dra&n a conclusion about the client%s response. The nurse must first compare the data &ith normal health problems to be able to arri e at a conclusion.'I(:A)*(:24-:omprehensionT0:#ursing 0rocess: 'iagnosis osby items and deri ed items ; 2<<, 2<<6 by osby, Inc., an affiliate of *lse ier Inc.  Test -an! $:#* test plan designation: 5ealth 0romotion and aintenance3.f the follo&ing statements, &hich one is an e8ample of an appropriately &ritten nursing diagnosis=1.Acute pain related to left mastectomy2.Impaired gas e8change related to altered blood gases3.'eficient !no&ledge related to need for cardiac catheteri9ation4.#eed for high protein diet related to alteration in client nutritionA#$:3This nursing diagnosis is &ritten correctly. It defines a problem and its etiology. In this case the problem is the client%s response to a diagnostic test. A medical diagnosis should not be recorded as the etiology because nursing inter entions cannot change the medical diagnosis. It &ould be appropriate to state acute pain related to impaired s!in integrity secondary to mastectomy incision. This nursing diagnosis is &ritten incorrectly because ituses supporti e data of the problem as the etiology. This nursing diagnosis does not identify the problem and etiology. It identifies the client%s goal rather than the problem. It could be re&orded as imbalanced nutrition: less than body requirements related to inadequate protein inta!e.'I(:A)*(:262-:omprehensionT0:#ursing 0rocess: 'iagnosis$:#* test plan designation: 5ealth 0romotion and aintenance4.f the follo&ing statements, &hich one is an e8ample of an appropriately &ritten nursing diagnosis= 1.)is! for change in body image related to cancer 2.ardiac output decreased related to motor ehicle accident3.Ineffecti e air&ay clearance related to increased secretions4.0otential for in>ury related to improper teaching in the use of crutchesA#$:3Ineffecti e air&ay clearance related to increased secretions is &ritten appropriately. It identifies a problem using a #A#'A International diagnostic statement and connects it toits etiology. )is! for change in body image related to cancer is &ritten incorrectly. It uses a medical diagnosis for the etiology. ardiac output decreased related to motor ehicle accident is &ritten incorrectly. The etiology is not treatable. 0otential for in>ury related to improper teaching in the use of crutches is &ritten incorrectly. It identifies the nurse%s  problem, not the client%s.'I(:A)*(:26<-:omprehensionT0:#ursing 0rocess: 'iagnosis$:#* test plan designation: 5ealth 0romotion and aintenance6.The nurse has diagnosed the client%s problem as altered elimination. (rom the database the nurse identifies all the follo&ing as appropriate etiologies for this diagnosis e8cept:1.0oor fiber inta!e osby items and deri ed items ; 2<<, 2<<6 by osby, Inc., an affiliate of *lse ier Inc. 1?72  Test -an! 2.imited fluid inta!e3.Total hip replacement 4.o&er abdominal discomfortA#$:3Total hip replacement because the medical diagnosis requires medical inter entions, it is legally inad isable to use it in the nursing diagnosis. )ather, the nurse should identify the client%s response, such as decreased mobility. The nurse should be able to pro ide nursinginter entions that &ill treat the etiology. 0oor fiber inta!e &ould be an appropriate etiology for the problem of altered elimination. imited fluid inta!e &ould be an appropriate etiology for the nursing diagnosis of altered elimination. o&er abdominal discomfort is an appropriate etiology for the nursing diagnosis of altered elimination.'I(:A)*(:24+-:omprehensionT0:#ursing 0rocess: 'iagnosis$:#* test plan designation: 5ealth 0romotion and aintenance@.The nurse is concerned that atelectasis may de elop as a postoperati e complication. hich of the follo&ing is an appropriate diagnostic label for this problem, should it occur=1.Impaired gas e8change2.'ecreased cardiac output3.Ineffecti e air&ay clearance4.Impaired spontaneous entilationA#$:1A potential etiology for impaired gas e8change may be atelectasis. Atelectasis &ould not support the diagnostic label for decreased cardiac output. Atelectasis &ould not be an etiology for ineffecti e air&ay clearance. Increased tenacious sputum production &ould  be a possible etiology for ineffecti e air&ay clearance. Impaired spontaneous entilation &ould not be an appropriate diagnostic label for atelectasis.'I(:A)*(:262-:omprehensionT0:#ursing 0rocess: 'iagnosis$:#* test plan designation: 5ealth 0romotion and aintenance?.The nurse recogni9es that &hich one of the follo&ing statements is true &ith regard to theformulation of nursing diagnoses=1.The diagnosis should identify a Bcause and effectC relationship.2.The diagnosis must remain constant during the client%s hospitali9ation.3.The etiology of the diagnosis must be &ithin the scope of the health care team%s  practice.4.The diagnosis should include the problem and the related contributing conditions.A#$:4 osby items and deri ed items ; 2<<, 2<<6 by osby, Inc., an affiliate of *lse ier Inc. 1?73  Test -an! The diagnosis should include the problem and the related contributing conditions is a truestatement. )elated factors are causati e or other contributing conditions that ha e influenced the client%s actual or potential response to the health problem and can be changed by nursing inter entions. The nursing diagnosis does not identify a Bcause and effectC relationshipD rather, it indicates that the etiology contributes to or is associated &ith the client%s problem. The nursing diagnosis does not ha e to remain constant during the client%s hospitali9ation. It should change according to changes in the patient. The etiology or cause of the nursing diagnosis must be &ithin the domain of nursing practice and a condition that responds to nursing inter entions, not those of the entire health care team.'I(:A)*(:263-:omprehensionT0:#ursing 0rocess: 'iagnosis$:#* test plan designation: 5ealth 0romotion and aintenance+.A diagnostic error can influence the application of the nursing care plan. A li!ely source for a nursing diagnosis error is if the nurse:1.Ealidates the assessment information in the data base2.Fses the #A#'A International list of diagnoses as a primary source3.(ormulates a diagnosis too closely resembling a medical diagnosis4.'istinguishes the nursing focus instead of other health care disciplines A#$:3A nursing diagnosis should identify the client%s response, not the medical diagnosis. -ecause the medical diagnosis requires medical inter entions, it is legally inad isable to include it in the nursing diagnosis. A nurse should alidate assessment data for accuracy and understanding. Fsing the #A#'A International list of diagnoses as a source helps to ensure accuracy. ne purpose the nursing diagnosis ser es is to distinguish the nurse%s role from that of the physician. Another purpose is to help nurses focus on the role of nursing in client care. #ursing diagnoses promote understanding bet&een nurses regarding clients% health problems.'I(:A)*(:24+-:/no&ledgeT0:#ursing 0rocess: 'iagnosis$:#* test plan designation: 5ealth 0romotion and aintenance.Identify the defining characteristics in the follo&ing nursing diagnosis: Altered speech related to recent neurological disturbance, as e idenced by inability to spea! in complete sentences.1.BAltered speechC2.BAs e idenced byC3.B)ecent neurological disturbancesC4.BInability to spea! in complete sentencesCA#$:4 osby items and deri ed items ; 2<<, 2<<6 by osby, Inc., an affiliate of *lse ier Inc. 1?74

Chapter 023

Jul 23, 2017

Chapter 021

Jul 23, 2017
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