PART A a. Database

Throughout the Nursing Process

b. Focused assessment c. Interview

d. Health assessment e. Nursing history

f. Objective data g. Physical assessment h. Subjective data

i. Validation j. Observation

k. Time-lapsed assessments PART B

1. Observable and measurable information that can be seen, heard, or felt by some-one other than the person experiencing it

2. The conscious and deliberate use of the five physical senses to gather information 3. Clearly identifies patient strengths and

weaknesses, health risks, and potential and existing health problems

4. A planned communication to obtain patient data

5. The examination of a patient for objec-tive data that may better define the patient’s condition and help the nurse in planning care

6. The act of confirming or verifying data 7. Compares a patient’s current status to

baseline data obtained earlier

DEVELOPING YOUR KNOWLEDGE BASE

FILL-IN-THE-BLANKS

1. The primary source of patient data is the patient, but two other sources of patient data are and .

2. The type of nursing assessment that is performed during the nurse’s initial contact with the patient and involves collecting data about all aspects of the patient’s health is

called the .

3. When a nurse confirms or verifies the data col-lected upon assessment to keep it free of error, bias, or misinterpretation, he/she is performing

the act of .

4. When a nurse asks a patient how having a newborn at home will affect her lifestyle, she is asking a(n) type of a question.

5. A nurse who gathers data about a newly diag-nosed case of hypertension in a 52-year-old African American patient is performing a(n)

type of assessment.

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8. Includes all the pertinent patient infor-mation collected by the nurse and other healthcare professionals, enabling a comprehensive and effective plan of care to be designed and implemented for the patient

9. The gathering of data about a specific problem that has already been identified 10. May be used by nurses to help patients

identify potential and actual health risks and to explore the habits, behaviors, beliefs, attitudes, and values that influence their health

Match the examples of data in Part B with the type of data in Part A. Answers will be used more than once.

PART A

a. Objective data b. Subjective data PART B

11. Redness and swelling are noticed at the site of an incision.

12. A patient complains of pain in his left arm.

13. A patient has a violent spell of coughing.

14. A patient recovering from knee surgery favors his impaired leg when walking.

15. A patient is nauseated at the sight of food.

16. A patient worries about her children during her hospital stay.

SHORT ANSWER

1. List the five functions of the initial comprehensive nursing assessment.

2. Identify eight sources of patient data, and give an example of each.

3. Briefly describe why the following characteris-tics of data are important when collecting and recording patient data.

a. Purposeful:

b. Complete:

c. Factual and accurate:

d. Relevant:

4. Give an example of three observations nurses should make each time they encounter a patient.

5. List three patient goals that should be accom-plished by the end of the introduction phase of the patient interview.

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6. Give two examples of closed questions, open-ended questions, and reflective questions that could be used to elicit information from your patient, a 42-year-old mother of three young children who has recently been diagnosed with diabetes; she is admitted to the hospital overnight for observation.

a. Closed questions:

b. Open-ended questions:

c. Reflective questions:

7. Explain how the following factors affect assessment priorities when collecting patient data.

a. Patient’s health orientation:

b. Patient’s developmental stage:

c. Patient’s need for nursing:

8. Give two examples of when data need to be validated.

9. Explain when the immediate communication of data is indicated.

APPLYING YOUR KNOWLEDGE

CRITICAL THINKING QUESTIONS

1. Role-play the following nursing interviews with your classmates:

a. A 50-year-old woman with diabetes and diabetic foot ulcers is admitted to the emer-gency room for observation after she expe-rienced a blackout.

b. An 85-year-old African American man is admitted to the coronary care unit after experiencing a possible stroke.

c. A teenage boy is admitted to the hospital with severe stomach pains and a possible ruptured appendix.

Talk about which approaches and types of questions (closed, open-ended, reflective, direct) resulted in the best interviews.

2. Recall the last time you went to a doctor’s office for a checkup or medical problem. How were you treated by the doctor’s staff? Did they do anything to make you feel comfortable or uncomfortable? What did they do to include you in the process? How did it feel to be a patient at the mercy of others? What would you do to incorporate this learning into your own nursing practice?

REFLECTIVE PRACTICE USING CRITICAL THINKING SKILLS

Use the following expanded scenario from Chapter 12 in your textbook to answer the questions below.

Scenario: Susan Morgan is a 34-year-old woman newly diagnosed with multiple sclero-sis. She was recently married to a man she met while hiking the Appalachian Trail. While educating Ms. Morgan about her disease, the nurse notices that she appears distressed and angry. Ms. Morgan says, “How am I going to tell my husband? We were just married last year and planned to do lots of hiking and outdoor sports. It’s not fair for him to be tied down to me if I can’t be the wife and partner that he thought he married.”

1. How might the nurse facilitate Ms. Morgan’s ability to cope with disability?

2. What would be a successful outcome for this patient?

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3. What intellectual, technical, interpersonal, and/or ethical/legal competencies are most likely to bring about the desired outcome?

4. What resources might be helpful for Ms. Morgan?

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Diagnosing

CHAPTER 13 PRACTICING FOR NCLEX

MULTIPLE CHOICE QUESTIONS

Circle the letter that corresponds to the best answer for each question.

1. Which of the following statements regarding nursing diagnoses is accurate?

a. Nursing diagnoses remain the same for as long as the disease is present.

b. Nursing diagnoses are written to identify diseases.

c. Nursing diagnoses are written to describe patient problems that nurses can treat.

d. Nursing diagnoses focus on identifying healthy responses to health and illness.

2. Which of the following is an actual or potential health problem that can be prevented or resolved by an independent nursing intervention?

a. Nursing diagnoses b. Nursing assessments

c. Medical diagnoses d. Collaborative problems

3. Which of the following would be an appropri-ate nursing diagnosis for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents’

negligence in providing a safe environment?

a. High Risk for Injury related to abusive parents

b. High Risk for Injury related to impaired home management

c. Child Abuse related to unsafe home environment

d. High Risk for Injury related to unsafe home environment

4. Which of the following nursing diagnoses would be written when the nurse suspects that a health problem exists but needs to gather more data to confirm the diagnosis?

a. Actual b. Potential

c. Possible d. Apparent

5. Which of the following nursing concerns is clearly the responsibility of the nurse?

a. Monitoring for changes in health status b. Promoting safety and preventing harm;

detecting and controlling risks c. Tailoring treatment and medication

regimens for each individual d. All of the above

ALTERNATE-FORMAT QUESTIONS Multiple Response Questions

Circle the letters that correspond to the best answers for each question.

1. Which of the following statements describe the purpose of diagnosing? (Select all that apply.)

a. To identify a disease in an individual, group, or community

b. To identify how an individual, group, or community responds to actual or potential health and life processes

c. To identify factors that contribute to, or cause, health problems (etiologies)

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d. To provide a legal record for actions performed by the nursing staff

e. To identify resources or strengths the indi-vidual, group, or community can draw on to prevent or resolve problems

f. To serve as a basis for the selection of nurs-ing interventions to achieve outcomes for which the nurse is accountable

2. Which of the following statements accurately describe a type of NANDA nursing diagnosis?

(Select all that apply.)

a. A wellness diagnosis has four components:

label, definition, defining characteristics, and related factor.

b. A possible diagnosis is a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness.

c. A risk nursing diagnosis is a clinical judgment that an individual, family, or community is more likely to develop the problem than others in the same or similar situation.

d. An actual diagnosis represents a problem that has been validated by the presence of major defining characteristics.

e. A potential nursing diagnosis is a statement describing a suspected problem for which additional data are needed.

f. A syndrome nursing diagnosis comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of certain events or situations.

3. Which of the following nursing diagnoses are written correctly? (Select all that apply.)

a. Deficient Fluid Volume related to abnormal fluid loss

b. Risk for Impaired Skin Integrity

c. Grieving related to Body Image Disturbance d. Possible Chronic Low Self-Esteem

e. Nutrition Deficit related to inability to eat a balanced diet

f. Knowledge Deficit related to noncompliance with physical therapy routine

4. Which of the following are accurate guidelines for writing nursing diagnoses? (Select all that apply.)

a. Phrase the nursing diagnosis as a patient need rather than a patient problem.

b. Check to make sure that the patient problem follows the etiology.

c. Make sure the patient problem and etiology are linked by the phrase “related to.”

d. Make sure defining characteristics follow the etiology and are linked by the phrase

“as manifested by” or “as evidenced by.”

e. Write nursing diagnoses in legally advisable terms.

f. Use defining characteristics and medical diagnoses in the problem statement.

5. Which of the following are parts of a nursing diagnosis? (Select all that apply.)

a. Problem b. Etiology

c. Patient needs

d. Defining characteristics e. Medical diagnosis

f. Legal parameters for nursing actions

DEVELOPING YOUR KNOWLEDGE BASE

FILL-IN-THE-BLANKS

1. When a nurse writes a patient outcome that requires pain medication for goal achievement, the situation is a(n) problem.

2. Patient complaints of chills and nausea are considered significant data or . 3. When determining the significance of a

patient’s urinalysis, the normative values to which the data can be compared are termed a(n) .

4. When a nurse groups patient cues that point to the existence of a patient health problem, the cues form what is known as a(n)

5. When a nurse recognizes a cluster of significant patient data indicating that patient teaching and counseling for a colostomy is needed, a(n)

should be written.

6. What part of the following nursing diagnosis would be considered the etiology: Spiritual Distress related to inability to accept the death of newborn child?

7. What two cues must be present for a valid wellness diagnosis? and

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8. nursing diagnoses comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.

MATCHING EXERCISES

Match the examples listed in Part B with the four steps involved in the interpretation and analysis of data listed in Part A. Answers will be used more than once.

PART A

a. Recognizing significant data b. Recognizing patterns or clusters c. Identifying strengths and problems d. Reaching conclusions

PART B

1. A nurse notes that a patient’s refusal to stop smoking will adversely affect his recovery from cardiac surgery.

2. A nurse compares a 15-month-old child’s motor abilities with the norms for that age group.

3. A nurse recognizes an unhealthy situation developing when her patient, recovering from a mastectomy, cries at night, refuses to eat, and sleeps all day.

4. A nurse decides no further nursing response is indicated for a woman who recovered from gallbladder surgery according to schedule.

5. A maternity nurse notices a newborn’s skin tone is markedly different than that of the other babies and checks for jaundice.

6. A nurse determines that a man with a his-tory of diabetes is highly motivated to develop a healthy pattern of nutrition in response to his problem.

7. A nurse notices that a patient with AIDS has an adverse reaction to a drug and consults the prescribing physician.

CORRECT THE FALSE STATEMENTS

Circle the word “true” or “false” that follows the statement. If you circled “false,” change the underlined word or words to make the statement true. Place your answers in the space provided.

1. Actual or potential health problems that can be prevented or resolved by independent

nursing intervention are termed collaborative problems.

True False

2. Medical diagnoses represent situations that are the primary responsibility of nurses.

True False

3. A cue is a generally accepted rule, measure, pattern, or model that can be used to compare data in the same class or category.

True False

4. A data cluster is a grouping of patient data or cues, which points to the existence of a patient health problem.

True False

5. Nursing diagnoses should be derived from a single cue.

True False

6. The NANDA list is a beginning list of suggested terms for health problems that may be identi-fied and treated by nurses.

True False

7. The problem statement of a nursing diagnosis identifies the physiologic, psychological, soci-ologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor.

True False

8. The etiology of nursing diagnoses directs nursing intervention.

True False

9. A possible nursing diagnosis is written when the nurse suspects that a health problem exists but needs to gather more data to confirm the diagnosis.

True False

10. A wellness diagnosis is a clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness.

True False

11. In the diagnosing step, the nurse collects patient data.

True False

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12. A possible nursing diagnosis is a clinical judgment that an individual, family, or com-munity is more likely to develop the problem than others in the same or similar situation.

True False SHORT ANSWER

1. Place a check next to the nursing diagnoses that are written correctly, and identify the errors in the incorrect diagnoses on the lines that follow.

a. ______ High Risk for Injury related to absence of restraints and side rails

b. ______ Impaired Skin Integrity related to mobility deficit

c. ______ Grieving related to loss of breast

d. ______ Self-Care Deficit: Bathing related to immobility

e. ______ Sleep Pattern Disturbance related to insomnia

f. ______ Alteration in Nutrition: Less Than Body Requirements related to loss of appetite

g. ______ Powerlessness related to poor family support system

h. ______ Anxiety: mild, related to changing lifestyle/diet

i. ______ Ineffective Airway Clearance related to 20-year smoking habit

j. ______ Alteration in Bowel Elimination:

Constipation related to cancer of bowel

k. ______ Nausea and Vomiting related to medication side effects

l. ______ Knowledge Deficit related to noncompliance with diet

m.______ Alteration in Parenting related to knowledge deficit: child growth and devel-opment, discipline

n. ______ Pain related to discomfort in abdomen

o. ______ Impaired Physical Mobility: amputa-tion of left leg related to gangrene

p. ______ Alteration in Nutrition: More Than Body Requirements related to obesity

q. ______ Noncompliance related to unresolved hostility

r. ______ Needs assistance walking to bathroom: related to immobility

2. What questions would you ask a patient to validate the following nursing diagnoses?

a. Altered Urinary Elimination:

b. Impaired Social Interaction:

c. Ineffective Individual Coping:

d. Sleep Pattern Disturbance:

3. Describe the appropriate nursing response to each of the following basic conclusions after interpreting and analyzing patient data.

a. No problem:

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b. Possible problem:

c. Actual or potential nursing diagnosis:

d. Clinical problem other than nursing diagnosis:

4. Give three examples of how standards may be used to identify significant cues.

5. List five questions a nurse should consider when using critical thinking in diagnostic reasoning.

6. In her book on the nursing process, Alfaro-LeFevre (2006) describes the shift from Diagnose and Treat (DT) to Predict, Prevent, Manage, and Promote (PPMP). The latter approach focuses on early evidence-based intervention to prevent and manage problems and their potential complications. Describe the three activities nurses need to perform to follow this approach in daily nursing care.

7. Read the three mini-cases that follow. In each one, underline the cues that form a data clus-ter indicating a nursing diagnosis, and write the appropriate nursing diagnosis as a three-part statement.

a. Mr. Klinetob, age 86, has been seriously depressed since the death 6 months ago of his wife of 52 years. Although he suffers

from degenerative joint disease and has talked for years about having “just a touch of arthritis,” this never kept him from being up and about. Recently, however, he spends all day sitting in a chair and seems to have no desire to engage in self-care activities. He tells the visiting nurse that he doesn’t get washed up anymore because he’s “too stiff” in the morning to bathe and

“I just don’t seem to have the energy.” The visiting nurse notices that his hair is matted and uncombed, his face has traces of previ-ous meals, and he has a strong body odor.

His children have complained that their normally fastidious father seems not to care about personal hygiene any longer.

Nursing Diagnosis:

b. Miss Adams sustained a right-sided cerebral infarct that resulted in left hemiparesis (paralysis on the left side of the body) and left “neglect.” She ignores the left side of her body and actually denies its existence.

When asked about her left leg, she stated that it belonged to the woman in the next bed—this while she was in a private room.

This patient was previously quite active:

she walked for 45 to 60 minutes four or five times a week and was an avid swimmer. At present, she cannot move either her left arm or leg.

Nursing Diagnosis:

c. After trying to conceive a child for 11 years, Ted and Rosemary Hines sought the assistance of a fertility specialist who was highly recommended by a friend. It was determined that Ted’s sperm was inad-equate, and Rosemary was inseminated with sperm from an anonymous donor. The couple was told that the donor was healthy and that he was selected because he resem-bled Ted. Rosemary became pregnant after the second in-vitro fertilization attempt and delivered a healthy baby girl named Sarah.

Sarah is now 7 years old, and Ted and Rosemary have learned from blood tests that their fertility specialist is the biologic

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father of their child. It seems that he lied to some couples about using sperm from anonymous donors and deceived others into thinking the wives had become pregnant when he had simply injected them with hormones. Ted and Rosemary have joined other couples in pressing charges against this physician.

Rosemary tells the nurse in her

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