CHAPTER 13 DIAGNOSING 67
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: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 actionsDEVELOPING YOUR
KNOWLEDGE BASEFILL-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? andLWBK696-C13_p66-71.qxd 9/2/10 9:25 AM Page 67 Aptara Inc