Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

68 UNIT III THE NURSING PROCESS

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:

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 diagnosesrepresent situations that

are the primary responsibility of nurses.

True False

3.A cueis 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 clusteris 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 listis a beginning list of suggested

terms for health problems that may be identi-

fied and treated by nurses.

True False

7.The problem statementof 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 etiologyof nursing diagnoses directs

nursing intervention.

True False

9.A possiblenursing 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 diagnosisis 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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