Nursing Diagnosis Assessment Quiz

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Questions and Answers

What should nursing diagnoses be derived from?

Previous medical history

Patient demographic information

Clusters of significant data (correct)

Single patient symptoms

Which of the following is an example of a strength that may indicate higher wellness levels?

A person with recent surgery

A person with multiple chronic illnesses

A person experiencing emotional distress

A person maintaining a balanced diet (correct)

What is the nurse likely trying to identify when observing signs of a wound infection?

Previous medications taken

Patient dietary habits

A normal body defense mechanism (correct)

The patient's psychology

Which of the following indicators may suggest a serious complication?

Changes in levels of consciousness Signup and view all the answers

After analyzing patient data, what conclusion might a nurse draw if there are no significant issues identified?

No Problem Signup and view all the answers

How many types of nursing diagnoses are described by NANDA?

Five Signup and view all the answers

What should a nurse conclude if the patient shows signs of inadequate coping but additional context suggests healthy emotional expression?

Misinterpretation of cues may have occurred Signup and view all the answers

Which of the following could not be considered a potential nursing diagnosis?

Transformation Signup and view all the answers

What is the primary purpose of the nursing process?

To design a personalized plan of care to improve patient outcomes Signup and view all the answers

Which patient could be diagnosed with 'Powerlessness' as a primary concern?

A patient struggling with sexual dysfunction Signup and view all the answers

What is a critical skill necessary for successful nursing outcome identification and planning?

High-level critical thinking skills Signup and view all the answers

In the nursing process, planning involves which of the following?

Setting priorities and identifying patient-centered goals Signup and view all the answers

Which nursing diagnosis pair would typically relate to a patient with a mastectomy focusing on emotional impacts?

Disturbed Body Image and Ineffective Coping Signup and view all the answers

What is emphasized regarding the nurse's plan of care?

It must be dynamic and adapt to the patient's changing needs. Signup and view all the answers

What should be taken into account when setting discharge goals for a patient?

Patient-centered care and the big picture of the patient's overall health Signup and view all the answers

Which of the following is NOT one of the steps in the nursing process described?

Documentation Signup and view all the answers

What does an actual nursing diagnosis represent?

A problem validated by the presence of major defining characteristics Signup and view all the answers

What component is NOT part of a risk nursing diagnosis?

Defining characteristics Signup and view all the answers

Which of the following best defines syndrome nursing diagnoses?

A collection of related actual or risk nursing diagnoses Signup and view all the answers

What element helps to clarify the meaning of a problem statement in nursing diagnoses?

Quantifiers or descriptors Signup and view all the answers

Which component identifies factors related to a nursing diagnosis?

Etiology Signup and view all the answers

What is the purpose of the problem statement in nursing diagnoses?

To clearly describe the patient's health state or problem Signup and view all the answers

What type of nursing diagnosis indicates a suspected problem requiring more data?

Possible nursing diagnosis Signup and view all the answers

What type of nursing diagnosis considers the likelihood of an individual developing a problem?

Risk nursing diagnosis Signup and view all the answers

What is a characteristic of long-term outcomes?

They serve primarily as discharge goals. Signup and view all the answers

Why is involving patients and families in outcome development important?

Involvement increases the likelihood of achieving the goals. Signup and view all the answers

Which of the following is an example of an observable and measurable outcome?

Patient will identify three coping strategies by the next visit. Signup and view all the answers

Which statement illustrates a common error in writing patient outcomes?

Patient will stop smoking and attend weekly support group meetings. Signup and view all the answers

What kind of verbs should be avoided when writing patient goals?

Know Signup and view all the answers

What distinguishes nursing diagnoses from medical diagnoses?

Nursing diagnoses focus on unhealthy responses to health and illness. Signup and view all the answers

Why is it important to check if the patient wants visitors to stay during a procedure?

To ensure the patient feels comfortable. Signup and view all the answers

What is a key consideration when identifying culturally appropriate outcomes?

The patient's personal values and beliefs. Signup and view all the answers

Which of the following represents a nursing diagnosis for a patient with a myocardial infarction?

Pain Signup and view all the answers

Which outcome is expressed correctly according to best practices?

By 4/12, patient will describe five benefits of exercise. Signup and view all the answers

Which term is used to denote significant data that influence a nurse's analysis?

Cue Signup and view all the answers

What should a nurse do if unsure about carrying out a planned intervention independently?

Seek help if needed. Signup and view all the answers

What is the significance of anticipating the necessary equipment for an intervention?

It helps in successfully carrying out the intervention. Signup and view all the answers

What should a nurse consider when interpreting a resting heart rate of 48 beats per minute in an athletic individual?

Recognize it might be a physiological norm. Signup and view all the answers

What is the purpose of establishing explicit linkages between NANDA diagnoses and NOC?

To create a more comprehensive approach to care planning. Signup and view all the answers

In the context of COPD, what oxygen saturation level might be considered normal?

88-92% Signup and view all the answers

How should a nurse approach the patient's dignity and privacy during interventions?

By ensuring the environment respects their privacy. Signup and view all the answers

What role does a patient's developmental stage play in implementing a care plan?

It helps tailor interventions to meet developmental needs. Signup and view all the answers

Which of the following diagnoses focuses on the impact of a stroke on a patient and their family?

Impaired verbal communication Signup and view all the answers

Why must nurses consider a patient's psychosocial background when planning interventions?

To ensure interventions are culturally relevant and acceptable. Signup and view all the answers

How many nursing diagnoses were identified in the first conference on nursing diagnosis in 1973?

80 Signup and view all the answers

What does the term 'data interpretation' refer to in nursing?

Analyzing significant data to inform patient care. Signup and view all the answers

What should be included in the nursing care plan to enhance patient independence?

Fostering self-care practices. Signup and view all the answers

What is the best approach for a nurse when implementing the care plan?

Collaborating with the patient and their support system. Signup and view all the answers

Study Notes

Assessment in Nursing Diagnosis

Nurses perform ongoing assessments throughout the nursing process.
The assessment establishes a database.
The patient's history provides information on health status, strengths, health problems, health risks, and need for care.
A physical examination is also a data-gathering method.
Assessment priorities should be identified based on the patient's condition and the purpose of the assessment.
Patient data should include patient information, family members, and healthcare professional reports.

Types of Nursing Assessments

First Assessment: Performed after the patient is admitted to establish a comprehensive database for problem identification and care planning. Data includes patient's health, priorities for ongoing focused assessments, and future comparison.
Focused Assessment: Used for a specific problem already identified, including what symptoms are present, when they began, anything different at onset, and what makes the symptoms better or worse.
Emergency Assessment: Performed when a physiologic or psychological crisis presents to identify life-threatening problems. Examples include choking, bleeding, stab wounds, and unresponsiveness.
Time-Lapsed Assessment: Scheduled to compare a patient's current status to baseline data obtained earlier. Useful for tracking changes over time, often involving vital signs taken at regular intervals.

Data Collection

Data collection must be structured systematically.
Gordon's Functional Health Patterns framework organizes data into patterns for analysis.
Maslow's Hierarchy of Needs provides a framework for analyzing basic human needs and ensuring those are met before prioritizing other needs.

Types of Data: Subjective and Objective

Subjective data: Information perceived only by the affected person; symptoms, feelings.
Objective data: Observable and measurable data; observable physical signs, lab results.

Data Collection - Characteristics

Purposeful: Nurses must identify the purpose (comprehensive, focused, etc.) for the assessment.
Complete: All necessary data relevant to current and potential problems.
Factual and Accurate: Data must be precise and detailed, not subjective interpretations.

Data Collection - Sources

Patient: The primary source of information.
Family and Significant Others: Important, especially with children or individuals with limited communication abilities.
Patient Records: Data collected by other healthcare providers.
Medical History, Physical Examination, Progress Notes: Documentation for medical professionals.
Consultations: Data from specialists related to the patient's care.
Laboratory Records: Laboratory tests data.
Diagnostic Studies, Radiographs, Therapies: Additional data collected or performed by healthcare teams.
Nursing and Other Healthcare Literature: Background knowledge to understand patient and health related issues.

Methods of Data Collection

Nursing History: Gathered as soon as possible after admission. Nurses should identify patient strengths, weaknesses, risk factors, and any existing health problems.
Patient Interview: A planned communication strategy where the nurse gathers information from the patient.
Nursing Physical Assessment: Physical exam that follows the nursing history. Nurses use their senses to gather objective data.

Data Reporting and Recording

Timeliness is critical. Critical changes in patient health should be reported immediately.
Documentation should be detailed using standard agency forms.

Diagnosing

Identifying patient problems/diagnoses
Ruling out similar issues/diagnoses
Clarifying contributing factors to health issues
Identifying risk factors that need management
Identifying patient strengths and resources.

History of Nursing Diagnoses

Origination of nursing diagnosis.
Key events in the development of nursing diagnosis.
Defining of nursing diagnoses.

Nursing Diagnosis vs. Medical Diagnosis

Nursing Diagnosis: Focuses on unhealthy responses to illnesses and health problems.
Medical Diagnosis: Focuses on diseases.

Data Interpretation and Analysis

Experienced nurses begin interpreting data during the collection process.
"Cue" is a term used to denote significant or relevant data.
Significant data should "raise a red flag" to indicate a priority concern during the assessment.
Interpretation should include identifying patterns in data for analysis and identifying possible contributing factors.

Recognizing Significant Data

Distinguish healthy responses from unhealthy ones.
Patient individual variation impacts normal readings. E.g: A healthy athlete may have a lower resting heart rate than a non-athlete.
Consider COPD; normal for a COPD patient might be an abnormal reading for someone without COPD.
Identify warning signs of problems.

Recognizing Patterns

Nursing diagnoses are derived from a cluster of significant data, not a single cue.
Patterns in data may show a problematic trend.

Identifying Strengths and Problems

Identifying patient strengths and possible problems; to inform care plan options.

Identifying Potential Complications

Potential medical complications or issues based on the diagnosis and treatment are identified.

Reaching Conclusions

Determining: (1) No Problem (2) Possible Problem (3) Actual or Potential Nursing Diagnosis (4) Clinical Problem Other Than Nursing Diagnosis

Formulating and Validating Nursing Diagnoses

Actual Diagnoses: Represent clearly identified problems, have defining characteristics.
Risk Diagnoses: Vulnerability to develop a problem.
Possible Diagnoses: Statements about a suspected problem requiring further data.
Syndrome Diagnoses: Clusters of actual or risk diagnoses linked to a significant event or situation.

Parts of Nursing Diagnosis Statements

Problem/Diagnosis: Clearly describes the patient's health state or condition.
Etiology: Identifies factors related to the problem.
Defining Characteristics: Subjective and objective data indicating the problem's existence.

Planning Nursing Care

Outcome identification and planning for patient outcomes.
Outcomes set priorities, goals, and interventions.
Collaboration with patients and families is crucial for patient-centered care.

Unique Focus of Nursing Outcome Identification and Planning

Create a plan of care to manage, reduce, or prevent patient problems.
Focused on patient outcomes.

Identifying and Writing Outcomes

Outcome criteria to achieve the nursing goals.
Identifying culturally appropriate outcomes for the patient in relation to their cultural background.
Avoid making outcomes as a Nursing intervention.

Identifying Nursing Interventions

Nurse-initiated Interventions: Actions performed without physician order.
Physician-initiated Interventions: Actions based on physician orders.
Collaborative Interventions: Actions performed by multiple healthcare team members.

Implementing The Plan of Care

Determining patient needs.
Organizing resources (equipment, environment, personnel).
Promoting self-care (Education/Counseling/Advocacy).
Assessing patient's response to interventions.

Critical Thinking and Implementing

Critical thinking regarding patient response to treatment and adjustments to the plan if necessary.
Evaluating if the plan of care is working based on the patient's response.
Adapting the intervention if patient shows different response to the implemented plan.
Knowing when to ask for help.

Types of Nursing Interventions

Independent: Nurse performs actions without physician input.
Dependent: Nurse carries out interventions based on physician or other provider orders.
Interdependent: Actions by the multidisciplinary team/care team.

Student Plans of Care

Provide more detailed plans than practice settings.
Used to assist students in understanding each step in the nursing process.

Implementing The Plan of Care-Determine The Patient's Need

Reassess the patient and the care plan regularly.
Organize resources for implementation.
Prioritize and promote patient's self-care.

Evaluating

Evaluating successful or unsuccessful outcomes based on measurable data.
Determining if outcomes are met.
Modify the care plan based on the results of the outcome evaluations.

Types of Outcomes

Cognitive outcomes: Involve increases in patient knowledge (e.g., teaching).
Psychomotor outcomes: Describe the patient's achievement of new skills.
Affective outcomes: Evaluate changes in feelings, emotions, or attitudes.
Physiologic Outcomes: Observable changes in the patient's physical state or function.

Time Criteria

Criteria, including the specific amount of time, is needed for achieving the outcome.

Documenting Judgement

Making a judgment about how outcomes were met.
Options include: "Met," "Partially met," or "Not met."

Modifying The Plan of Care

Revising the care plan based on evaluation results and to improve patient outcomes. This might involve changing diagnoses, outcomes or interventions if they are failing to meet the goals.

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Description

This quiz covers the essential aspects of assessment in nursing diagnosis, including the types of assessments and data collection methods. It focuses on how nurses gather information to establish a patient database for effective care planning and problem identification. Test your knowledge on the priorities and techniques used in nursing assessments.