Critical Thinking and Nursing Process > Fundamentals
Exam Review
Diagnosis
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is reviewing the diagnostic statements of a client who has multiple health problems. Which of the following statements is an example of an actual diagnosis?
Explanation
Choice A reason:.
This is not an example of an actual diagnosis because it describes a potential problem that has not yet occurred. An actual diagnosis identifies a problem that is present at the time of the assessment and is based on signs and symptoms.
Choice B reason:.
This is an example of an actual diagnosis because it describes a problem that is present at the time of the assessment and is based on signs and symptoms. An actual diagnosis consists of three components: the problem, the etiology, and the defining characteristics. In this case, the problem is impaired skin integrity, the etiology is related to pressure ulcer, and the defining characteristics are evidenced by 4 cm x 3 cm wound on sacrum.
Choice C reason:.
This is not an example of an actual diagnosis because it does not include any defining characteristics that support the problem. An actual diagnosis requires evidence of signs and symptoms to validate the problem.
Choice D reason:.
This is not an example of an actual diagnosis because it describes a readiness to enhance a specific health behavior rather than a problem that is present at the time of the assessment. A readiness for enhanced diagnosis identifies a strength or potential for improvement in a client's health status.
A nurse is assessing a client who has a fever and reports feeling cold. The nurse observes that the client is shivering and has goosebumps on his skin. Which of the following terms should the nurse use to describe these findings in the diagnostic statement?
Explanation
Choice A reason:.
Problem is not the correct term to describe these findings because it is too vague and does not specify the human response to the health condition. A problem is a general label that can apply to many situations, but a nursing diagnosis should be more precise and descriptive.
Choice B reason:.
Etiology is not the correct term to describe these findings because it refers to the cause or contributing factors of the problem, not the problem itself. Etiology is usually preceded by the phrase "related to”. in a nursing diagnostic statement. For example, "Impaired skin integrity related to pressure ulcer”. is a nursing diagnosis where "pressure ulcer”. is the etiology.
Choice C reason:.
Defining characteristics is the correct term to describe these findings because it refers to the observable and verifiable signs and symptoms that indicate the presence of a problem or risk. Defining characteristics are usually preceded by the phrase "as evidenced by”. in a nursing diagnostic statement. For example, "Acute pain as evidenced by grimacing, guarding, and increased heart rate”. is a nursing diagnosis where "grimacing, guarding, and increased heart rate”. are the defining characteristics.
Choice D reason:.
Related factors is not the correct term to describe these findings because it refers to the conditions or circumstances that are associated with the problem or risk, but are not necessarily the cause. Related factors are usually preceded by the phrase "related to”. in a risk nursing diagnostic statement. For example, "Risk for falls related to impaired balance”. is a nursing diagnosis where "impaired balance”. is a related factor.
A nurse is caring for a client who has a history of substance abuse and is at risk for withdrawal. The nurse plans to monitor the client for signs of anxiety, agitation, and tremors. Which of the following types of diagnosis should the nurse use for this client?
Explanation
Choice A reason:
An actual diagnosis is based on the presence of associated signs and symptoms, not on the risk of developing them. The client in the question does not have any signs or symptoms of withdrawal yet, only a history of substance abuse. Therefore, an actual diagnosis is not appropriate for this client.
Choice B reason:
A risk diagnosis is based on the presence of risk factors that increase the likelihood of developing a problem or dysfunction. The client in the question has a history of substance abuse, which is a risk factor for withdrawal. The nurse plans to monitor the client for signs of anxiety, agitation, and tremors, which are potential indicators of withdrawal. Therefore, a risk diagnosis is appropriate for this client.
Choice C reason:
A health promotion diagnosis is based on the desire to enhance well-being and human potential. The client in the question does not express any desire to improve their health or well-being, nor does the nurse plan to implement any interventions to promote health. Therefore, a health promotion diagnosis is not appropriate for this client.
Choice D reason:
A wellness diagnosis is based on the presence of a transition from one level of wellness to a higher level of wellness. The client in the question does not show any evidence of a transition or a higher level of wellness, nor does the nurse plan to facilitate any wellness activities. Therefore, a wellness diagnosis is not appropriate for this client.
A nurse is evaluating a client who has expressed a desire to quit smoking. The client states that he has reduced his cigarette consumption by half and has joined a support group. Which of the following types of diagnosis should the nurse use for this client?
Explanation
Choice A reason:
An actual diagnosis is based on the presence of associated signs and symptoms of a health problem. The client does not have any signs or symptoms of a health problem related to smoking, but rather has expressed a desire to quit smoking and has taken some steps to do so.
Choice B reason:
A risk diagnosis is based on the presence of risk factors that increase the vulnerability of a person or group to develop a health problem. The client does not have any risk factors that increase his vulnerability to develop a health problem related to smoking, but rather has reduced his cigarette consumption by half and has joined a support group.
Choice C reason:
A health promotion diagnosis is based on the desire to enhance well-being and can be expressed by a readiness to enhance specific health behaviors. The client has expressed a desire to quit smoking, which is a specific health behavior that can enhance his well-being. Therefore, this is the correct type of diagnosis for this client.
Choice D reason:
A wellness diagnosis is based on the presence of potential or actual levels of wellness in an individual, family, or community that can be enhanced. The client does not have any potential or actual levels of wellness related to smoking, but rather has a desire to quit smoking and improve his health. Therefore, this is not the correct type of diagnosis for this client.
A nurse is formulating a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. Which of the following components should the nurse include in the statement? (Select all that apply.).
Explanation
Choice A reason:
The problem is the first component of a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. The problem is the nursing diagnosis that describes the client's health status in response to the actual or potential health problem. For example, the problem could be impaired skin integrity, risk for infection, or chronic pain.
Choice B reason:
The etiology is not a component of a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. The etiology is the cause or contributing factor of the problem. For example, the etiology could be diabetes mellitus, peripheral neuropathy, or poor circulation.
Choice C reason:
The signs and symptoms are the third component of a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. The signs and symptoms are the evidence or data that support the problem. For example, the signs and symptoms could be ulceration, numbness, or tingling.
Choice D reason:.
The medical diagnosis is not a component of a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. The medical diagnosis is the identification of a disease or condition by a physician or other health care provider based on scientific criteria. For example, the medical diagnosis could be diabetes mellitus type 1 or type 2, or peripheral neuropathy.
Choice E reason:
The nursing interventions are not a component of a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. The nursing interventions are the actions or treatments that the nurse plans and implements to address the problem. For example, the nursing interventions could be wound care, education, or medication administration
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