Diagnosis
Diagnosis ( 5 Questions)
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?
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.
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.
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.
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.
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.