Questions and Answers
What must the nurse ensure regarding the related factor for a nursing diagnosis?
It is a condition that responds to nursing interventions.
Which client is likely to have a health promotion nursing diagnosis?
What should the nurse do when the defining characteristics of assessment data for a client can apply to more than one diagnosis? (Select all that apply)
What is the correct order of steps of the nursing diagnostic process?
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Which features distinguish nursing diagnoses from medical diagnoses? (Select all that apply)
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Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?
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A child being treated with cardiac drugs developed certain symptoms. Which drug toxicity is responsible for these symptoms?
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Which diagnosis made by the nurse is most helpful in providing the right nursing interventions for the client?
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What benefits are associated with using standard formal nursing diagnostic statements? (Select all that apply)
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What is critical thinking?
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What is the nursing process?
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What are the phases of the nursing process?
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What is evaluating?
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What is full spectrum nursing?
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What are the types of nursing diagnoses?
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Which is the next step in the nursing process for a postsurgical client who becomes short of breath with little exertion?
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What is true about conducting nursing assessments? (Select all that apply)
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Which information is considered primary data during a client's appointment at the women's clinic? (Select all that apply)
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Which is the best explanation of the difference between a medical diagnosis and a nursing diagnosis?
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Using Maslow's hierarchy of needs, place the nursing diagnoses in order of priority.
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Which type of intervention has the nurse implemented when explaining the importance of using oxygen to the client with chronic obstructive pulmonary disease?
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What does the evaluative statement, 'Circulation status: 3,' mean according to the Nursing Outcome Classification (NOC)?
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How can the nurse promote client participation and adherence to the nursing plan with a postoperative bariatric client? (Select all that apply)
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Which is the priority nursing diagnosis for a client experiencing increasing shortness of breath and labored breathing?
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During an assessment, if a nurse notes that the client has an elevated temperature, what type of data is this?
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According to Maslow's Hierarchy of Needs, what is the appropriate order of priority of the client needs?
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Which describes the central source of information needed to guide holistic, goal-oriented care?
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What action should the nurse take when a client is unable to ambulate due to obesity and pain?
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Which is an example of a nurse using subjective data to clarify objective data?
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Which is an important consideration for discharge planning for a client using a walker after hip surgery?
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Which is a valid goal statement for measuring and managing pain?
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Which describes the correct way to state a nursing diagnosis?
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When creating a care plan, which outcomes can be influenced by nursing interventions?
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What is the appropriate action if a nurse considers 'anxiety' as a nursing diagnosis but lacks sufficient information?
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Who has accountability for the actions performed and the outcome when a task is delegated to a nursing assistant?
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Which scenario is an example of a lifestyle factor that influences sleep?
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With prolonged use, which medication may cause yellow discoloration of a child's teeth?
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What condition may a client have if they report pain in the nose and difficulty breathing after a fall while playing football?
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Which assessment activity enabled the nurse to derive the conclusion of a related factor as first time surgery?
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How should the nurse document the nursing diagnosis according to NANDA-I?
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Which related factor is appropriate for a nursing diagnosis?
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Study Notes
Nursing Process and Assessments
- Reevaluating and creating a new nursing diagnosis based on client findings allows for updated interventions and goals.
- Nursing assessments must be completed within 24 hours of inpatient admission and cannot be delegated.
- All clients should be assessed for pain, nutritional status, and fall risk as per The Joint Commission standards.
Data Collection and Nursing Diagnoses
- Primary data includes subjective and objective information from the client, such as heavy menstrual flow and its connection to anemia.
- A medical diagnosis identifies illness and pathology, while a nursing diagnosis focuses on the client's health status and nursing interventions.
- The priority of nursing diagnoses based on Maslow's hierarchy: airway clearance takes precedence over breathing patterns, fluid volume, fall risk, wandering, and memory impairment.
Interventions and Outcomes
- Interdependent interventions indicate collaboration with healthcare team members, such as respiratory therapists for oxygen usage.
- The Nursing Outcome Classification scale classifies circulation status; a rating of 3 indicates moderate compromise.
- Promoting client participation in a nursing plan includes ensuring comfort in questions, simplicity in instructions, alignment of goals, and setting realistic expectations.
Specific Nursing Considerations
- Ineffective breathing patterns are a priority nursing diagnosis when a client exhibits increasing shortness of breath.
- Objective data, such as an elevated temperature, is measurable and used to inform nursing diagnoses.
- Comprehensive nursing care plans are crucial for addressing unique client needs holistically.
Client Education and Discharge Planning
- To facilitate care while helping a client with ambulation, seeking assistance is crucial if the client is unable to move independently.
- Valid pain management goals should be specific and measurable, such as reporting pain levels.
- A nursing diagnosis must convey a problem, related factor, and connecting phrase, adhering to NANDA-I standards.
Lifestyle Factors and Health Promotion
- Lifestyle factors can greatly affect sleep patterns, as seen in clients with irregular work shifts who struggle with fatigue.
- Tetracycline is known to cause yellowing of teeth in children with prolonged use.
- Clients expressing a desire to improve health behaviors, such as walking daily, may be given a health promotion nursing diagnosis.
Assessment Challenges
- When assessment data applies to multiple diagnoses, further information must be gathered, related factors identified, and defining characteristics reviewed to clarify the situation.### Nursing Diagnostic Process
- Correct interpretation of information enables accurate selection of nursing diagnoses.
- Related factors provide context for defining client characteristics.
- Individualizing nursing diagnoses requires identification of related factors.
- Review and confirm relevant defining characteristics while eliminating irrelevant ones.
- Data clusters form after thorough reassessment and validation of assessment data.
- Not all diagnoses need rejection; review supports relevant diagnosis confirmation.
Steps of the Nursing Diagnostic Process
- First, assess the client's health status through data gathering.
- Validate collected data with other sources to ensure accuracy.
- Interpret the meaning of the validated data for understanding client needs.
- Cluster data to identify relationships between findings.
- Look for defining characteristics that indicate the client's health issues.
- Identify client’s needs based on the diagnostic information.
- Formulate nursing diagnoses based on identified health problems.
Differences Between Nursing and Medical Diagnoses
- Nursing diagnoses actively involve the client in the assessment and care process.
- Medical diagnoses focus on disease conditions identified via diagnostic tests.
- Nursing diagnoses classify health issues to be treated within the nursing domain and reflect clinical judgment of client responses.
Importance of Nursing Diagnosis
- Planning phase of the nursing process relies heavily on established nursing diagnoses.
- A clear and accurate diagnosis is essential for appropriate planning and intervention.
Symptoms of Digoxin Toxicity
- The digoxin toxicity is indicated by symptoms such as vomiting, bradycardia, and dysrhythmias.
- Digoxin improves heart efficiency, but overdose can lead to serious complications.
Diagnostic Labels
- Diagnostic labels encapsulate the essence of a client's response to health conditions.
- Labels are concise representations of nursing diagnoses, approved by NANDA-I.
Characteristics of Risk Nursing Diagnoses
- Risk diagnoses lack defined related factors since they indicate potential responses not yet manifested.
- These diagnoses focus on preventive measures for vulnerable individuals and populations.
Benefits of Standard Nursing Diagnostic Statements
- Foster the development of nursing knowledge and clinical understanding.
- Provide precise definitions of client problems, aiding clear communication.
- Distinguish nursing roles from other healthcare providers, emphasizing nurses' responsibilities.
Critical Thinking in Nursing
- Critical thinking is purposeful, analytical, and results in informed decision-making.
- Essential for holistic care, combining various knowledge fields and skills in fast-paced environments.
Phases of the Nursing Process
- Assessment: Initial data gathering about the client's health.
- Diagnosis: Identification of client health needs based on assessment.
- Planning: Establishing goals and interventions to be implemented.
- Implementation: Executing planned interventions to support client care.
- Evaluation: Assessing the effectiveness of interventions and overall client outcomes.
Types of Nursing Knowledge
- Theoretical knowledge rooted in evidence and theory.
- Practical knowledge gained through hands-on experience.
- Self-knowledge reflecting on personal beliefs and practices.
- Ethical knowledge guiding moral and ethical decision-making.
Types of Nursing Diagnoses
- Actual diagnoses indicate current health issues.
- Risk diagnoses suggest potential health risks.
- Possible diagnoses identify areas needing further assessment.
- Wellness diagnoses promote optimal health states.
- Syndrome diagnoses encapsulate collective health responses.
Delegation
- Nurses must not delegate interventions requiring specialized knowledge or judgment.
- The "Five Rights of Delegation" ensure safe and effective delegation to appropriate personnel.
Cultural Concepts in Nursing
- Bicultural individuals identify with and integrate multiple cultures.
- Multiculturalism refers to diverse cultural groups.
- Ethnocentrism is the belief in the superiority of one's own culture.
- Vulnerable populations include groups at higher risk for health issues due to socioeconomic factors.
Safety and Developmental Factors
- Safety varies across developmental stages:
- Infants and toddlers lack danger recognition.
- Preschoolers are adventurous but need supervision.
- School-age children face risks from unfamiliar environments.
- Adolescents engage in risky behavior due to a sense of invincibility.
- Adults may face workplace injuries and health decline with age.
- Older adults often experience physiological changes that impact safety.
Health Problems
- Defined as conditions requiring intervention to prevent or resolve disease and support wellness.
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Explore essential nursing process concepts through flashcards covering LP 4, 5, and 6. This quiz focuses on the next steps in care for postsurgical clients, emphasizing assessment and decision-making skills. Perfect for nursing students preparing for practical applications.