Diagnosis

Question 1

• The second phase of the nursing process
• Pivotal step in the nursing process

Answer 1

Diagnosing

Question 2

In the diagnosing phase, the nurse uses __________ to interpret assessment data and identify client strengths and problems.

Answer 2

critical thinking skills

Question 3

Activities preceeding the diagnosing phase are directed toward formulating the __________

Answer 3

nursing diagnoses

Question 4

Refers to the reasoning process

Answer 4

Diagnosing

Question 5

Statement or conclusion regarding the nature of a phenomenon

Answer 5

Diagnosis

Question 6

Contains a diagnostic phrase or diagnostic label followed by an etiology phase

Answer 6

Nursing Diagnosis

Question 7

Statement of the client’s problem

Answer 7

Diagnostic Phrase

Question 8

Causal relationship between the client’s problem or risk factors

Answer 8

Etiology

Question 9

• Responsible for making nursing diagnoses
• Accountable for analyzing data to determine diagnoses or issues

Answer 9

Professional Nurses (registered nurses)

Question 10

Are not educated to diagnose or treat diseases such as diabetes mellitus

Answer 10

Generalist Nurses

Question 11

Nursing diagnoses describe a continuum of health states:
- (1) __________ from health
- (2) presence of __________
- (3) areas of enhanced __________

Answer 11

(1) deviations
(2) risk factors
(3) personal growth

Question 12

• Is also known as a problem-based diagnosis
• Is a client problem that is present at the time of the nursing assessment
• Based on the presence of associated signs and symptoms

Answer 12

Actual Nursing Diagnosis

Question 13

• Client’s preparedness to implement behaviors
• Willingness to learn about health maintenance
• Willingness to change health practices

Answer 13

Health Promotion Diagnosis

Question 14

• Clinical judgement that a problem does not exist
• Presence of risk factors indicates that a problem is likely to develop unless nurses intervene

Answer 14

Risk Nursing Diagnosis

Question 15

• Clinical nursing judgement when a client has several similar nursing diagnoses

Answer 15

Syndrome Diagnosis

Question 16

• Describes the client’s health problem and client’s health status
• Directs the formation of client goals and described outcomes

Answer 16

Problem Statement / Diagnostic Label

Question 17

• Added to the nursing diagnosis to provide additional meaning to the diagnostic statement

Answer 17

Qualifiers

Question 18

• Identifies one or more probable causes of the health problem, gives direction to nursing therapies, and enables individualization of client’s care
• Clarifies the meaning of the diagnosis

Answer 18

Etiology

Question 19

• Cluster of signs and symptoms that indicate the presence of a particular diagnostic label
• Client’s signs and symptoms

Answer 19

Defining Characteristics

Question 20

• Provides a way to describe the client’s area of concern
• Clinical judgement that concerns a human response to a health condition that nurses, by virtue of thier education, experience, and expertise, are licensed to treat

Answer 20

Nursing Diagnosis

Question 21

• Made by a physician
• Refers to a condition that only a physician can treat
• Refer to the disease processes: specific pathophysiologic responses that are fairly uniform from one client to another

Answer 21

Medical Diagnosis

Question 22

Nursing diagnoses relate primarily to the nurse’s ___________, which are the areas of healthcare that are unique to nursing and separate and distinct from medical management

Answer 22

independent functions

Question 23

With regard to medical diagnoses, nurses are obligated to carry out physician-prescribed therapies and treatements, that is, __________

Answer 23

dependent functions

Question 24

• A type of potential problem that nurses manage using both independent and physician-prescibed interventions

Answer 24

Collaborative Problem

Question 25

- Is the separation into components of the diagnostic process - Breaking down of the whole into its parts

Answer 25

Analysis

Question 26

- Putting together of parts intot the whole (inductive reasoning)

Answer 26

Synthesis

Question 27

The diagnostic process is used __________ by most nurses

Answer 27

continuously

Question 28

The diagnostic process has three steps: - Analyzing (1) __________ - Identifying (2) __________ - Formulating (3) __________

Answer 28

(1) data (2) health problems, risks, and strengths (3) diagnostic statements

Question 29

In the diagnostic process, analyzing involves the following steps: 1. Compare the data against (1) __________ 2. Cluster the (2) __________ 3. Identify (3) __________

Answer 29

(1) standards (2) cues (3) gaps and inconsistencies

Question 30

Is generally a accepted measure, rule, model, or pattern

Answer 30

Standard / Norm

Question 31

A process of determining the relatedness of facts and determining whether any patterns are present, whether the data represent isolated incidents, and whether the data are significant

Answer 31

Clustering Cues

Question 32

- Are conflicting data - Measurement error, expectations, and inconsistent or unreliable reports

Answer 32

Inconsistencies

Question 33

The basic two-part diagnostic statements includes the following: 1. __________: the statement of the client’s response 2. __________: factors contributing to or probable causes of the responses

Answer 33

Problem (P) Etiology (E)

Question 34

The two parts of the diagnostic statement are joined by the words (1) _______ rather than (2) _______

Answer 34

(1) related to (2) due to

Question 35

For a nursing diagnosis that contains the word “__________”, the nurse must add words to indicate the problem more specifically.

Answer 35

“specify”

Question 36

TRUE OR FALSE Write diagnostic statements as they would be stated in normal conversation e.g., Potential for infection

Answer 36

TRUE

Question 37

The basic three-part nursing diagnosis statement

Answer 37

PES Format

Question 38

The PES Format for diagnostic statements include the following: 1. __________: statement of the client’s response 2. __________: factors contributing to or probable causes of the response 3. __________: defining characteristics manifested by the client

Answer 38

(1) Problem (P) (2) Etiology (E) (3) Signs & Symptoms (S)

Question 39

The PES format cannot be used for _________ because the client does not have signs and symptoms of the diagnosis

Answer 39

risk diagnoses

Question 40

To minimize long problem statements, the nurse lists the __________ on the care plan below the nursing diagnosis, grouping the subjective (S) and objective (O) data.

Answer 40

signs and symptoms

Question 41

Some diagnostic statements, such as health promotion diagnoses and syndrome nursing diagnoses, consist of a __________ only.

Answer 41

nursing diagnosis label (one-part statements)

Question 42

Writing __________ when the defining characteristics are present but the nurse does not know the cause or contributing factors

Answer 42

unknown etiology (Non-adhereance to medical regimen related to UNKNOWN ETIOLOGY)

Question 43

Using the phrase __________ when there are too many etiologic factors or when they are too complex to state in a brief phrase.

Answer 43

complex factors (Chronic pain related to COMPLEX FACTORS)

Question 44

When the nurse believes that more data are needed about the client’s problem or etiology, the word ________ is inserted.

Answer 44

possible (Alteration in throught processes POSSIBLY related to unfamiliar surroundings)

Question 45

Using __________ to divide the etiology into two parts, following a pathopysiologic or disease process or medical diagnoses

Answer 45

secondary to (Impaired skin integrity related to decreased peripheral circulation SECONDARY to diabetes)

Question 46

Adding a __________ to the general response or nursing diagnosis label to make it more precise

Answer 46

second part (Altered skin integrity [LEFT LATERAL ANKLE] related to decreased peripheral circulation)