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SHOPE CH. 16
Question | Answer |
---|---|
A nursing diagnosis is: | A statement of the client response to a health problem that requires nursing intervention |
The first part of the nursing diagnosis statement: | Identifies and actual or potential health problem. |
The second part of the nursing diagnosis statement: | Identifies the probable cause of the client problem. |
Which of the following is the correctly stated nursing diagnosis? | Needs to be fed related to broken right arm. |
52 y/o admitted to CCU. Denies chest pain, SOB, normal pulse and bp. Appears tense, doesn't want RN to leave bedside, states he's nervous. Which nursing diagnosis is appropriate? | Anxiety related to ICU admission. |
Actual nursing diagnosis | Describes human responses to health conditions/life processes that exist in an individual, family or community. Judgement supported by defining characteristics. |
Client centered problems | Forming nursing diagnosis and individual care plan. |
Collaborative problems | Actual or potential physio. complications that can result from disease, trauma, Tx, Dx studies where nurses intervene in collaboration. |
Defining characteristics | The clinical criteria or assessment findings that support (validate) an actual nursing diagnosis. |
Diagnostic process | Includes decision making steps, gathering assessment database, validating, analyzing, interpreting data, ID Pt. needs and forming nursing Dx. |
Etiology | Cause of nursing diagnosis |
Medical Diagnosis | ID of a disease condition based on specific evaluation of S/S, Hx, and results of Dx procedures. |
NANDA International | Provides a common language for health problems nurses deal with. |
Nursing Diagnosis | Clinical judgement about individual, family, or community responses to actual or potential health problems or life processes. |
Risk Nursing Diagnosis | Describes human response to health conditions/life processes that may develop in a vulnerable individual, family, or community. |
Wellness Nursing Diagnosis | Describes human responses to levels of wellness in individ., fam., community that have a readiness for enhancement to higher level of wellnes. |
This organization is the leader in nursing diagnosis classification: | NANDA. Endorsed by ANA. |
One of the purposes of the use of standard formal nursing diagnostic statements is to: | Help nurses focus ont eh role of nursing in client care, among other purposes. |
Critical thinking is: | An active, organized, cognitive process used to carefully examine one's thinking and the thinking of others. |
The nursing diagnosis: Family coping: potential for growth r/t unexpected birth of twins is an example of a: | Wellness diagnosis-describes response to level of wellness in an individual ready for enhancement. |
The nursing diagnosis: Risk for impaired skin integrity is an example of a: | A risk nursing diagnosis-developing in a vulnerable person ie. spine injury |
The word impaired in the diagnosis Impaired physical mobility is an example of: | A discriptor- a diagnostic are used to give additional meaning to the diagnosis. |
Nurse using auscultation to obtain a pulse is an example of: | Objective measurement |
A practice to avoid data collection errors is: | Asking a coworker to see if they can validate the same finding. |
"Unhappy and worried about health" is not a scientifically based diagnosis, and it can lead to error in: | Diagnostic statement. Needs to be more precise like ineffective individual coping r/t fear of medical Dx. |