NUR 340 Exam #2 Questions With Complete Solutions
primary data
Information provided by the patient
What actions constitute a violation of client privacy,
confidentiality, and professionalism?
- One of your primary ethical responsibilities is safeguarding
privacy of your patients
- You need to ask family members to step outside of the room of
a patient you are about to assess unless patient gives consent for
them to be present
- National council of state boards of nursing provides guidelines
on social media for nurses: maintaining privacy on social media
diagnosing problem identification
second step of nursing process occurs after nurse collected and
recorded patient data
now the nurse is interpreting and analyzing all collected data
purposes of diagnosing/analyzing
identify how a person or group or community responds to actual
or potential health and life processes
identify factors that contribute to health problems = etiologies
identify resources or strengths that the person group or
community can draw on to prevent or resolve problems
nursing diagnosis
,actual or potential health problem that an independent nursing
intervention can prevent or resolve.
Actual problem is present.
Possible problem may be present, but more data are needed to
confirm or disconfirm the problem.
Potential problem may occur; defining characteristics are
present as risk factors.
health problem
a condition that necessitates intervention to prevent or resolve
disease or illness or to promote coping and wellness
What are the guidelines for composing a nursing diagnosis
statement?
· Phrase diagnostic statement as an actual or potential diagnosis,
problem, or issue
· Check to make sure that the problem precedes etiology
· Consider when at risk populations or associated conditions
should be identified
· Signs and symptoms should follow etiology
· Write in legally advisable terms
· Use non judgmental language
· Problem statement should indicate what is unhealthy about the
patient or what patient wants to change
· Avoid using defining characteristics, medical diagnoses or
something that cannot be changed in problem statement
· Reread diagnosis to make sure that the problem statement
suggests patient outcomes and that etiology will direct selection
of nursing measures
,three components of problem focused nursing statement
problem, cause, signs/symptoms
problem
describes health state or healthy problem as clearly and concise
as possible
identifies what it healthy about patient, what patient wants to
change
cause/etiology
factors that are maintaining unhealthy patient state
suggests appropriate nursing measures
physiological, psychological, sociological, spiritual,
environmental
signs and symptoms
subjective and objective data that signal existence of a problem
(cue)suggest evaluative criteria
Review and define what is meant by a "risk nursing diagnosis"
Risk nursing diagnosis= clinical judgement concerning the
vulnerability of an individual, family, group or community for
developing an undesirable human response to health
conditions/life processes
problem-focused nursing diagnosis
a clinical judgment concerning an undesirable human response
to a health condition/ life process that exists in an individual,
family or community
, health promotion diagnosis
a concern with which a healthy person desires nursing assistance
to maintain or achieve a higher level of wellness
Why would you want to be cautious when documenting that a
patient is non-compliant and hostile in their chart
Things to consider Multiple factors may underlie the client's
response to education in a complex and emotionally charged
situation, such as receiving a new ostomy. As a result, it is likely
presumptuous to ascribe the client's response to hostility.
common sources of misdiagnosis
o Premature diagnosis based on incomplete database.
o Erroneous diagnoses resulting from an inaccurate database or
faulty data analysis.
o Routine diagnoses resulting from the nurse's failure to tailor
data collection and analysis to the unique needs of the patient.
o Errors of omission (failure to modify)
When writing a nursing diagnosis review the importance of
validation
- Computers cannot replace humans and critical thinking, you
will need to validate your diagnostic statements and recognize
when your computer is making an obvious error
· Is my patient database sufficient, accurate and supported by
nursing research
· Does my synthesis of data demonstrate pattern existence
· Is my tentative problem statement based on scientific nursing
knowledge and clinical expertise
primary data
Information provided by the patient
What actions constitute a violation of client privacy,
confidentiality, and professionalism?
- One of your primary ethical responsibilities is safeguarding
privacy of your patients
- You need to ask family members to step outside of the room of
a patient you are about to assess unless patient gives consent for
them to be present
- National council of state boards of nursing provides guidelines
on social media for nurses: maintaining privacy on social media
diagnosing problem identification
second step of nursing process occurs after nurse collected and
recorded patient data
now the nurse is interpreting and analyzing all collected data
purposes of diagnosing/analyzing
identify how a person or group or community responds to actual
or potential health and life processes
identify factors that contribute to health problems = etiologies
identify resources or strengths that the person group or
community can draw on to prevent or resolve problems
nursing diagnosis
,actual or potential health problem that an independent nursing
intervention can prevent or resolve.
Actual problem is present.
Possible problem may be present, but more data are needed to
confirm or disconfirm the problem.
Potential problem may occur; defining characteristics are
present as risk factors.
health problem
a condition that necessitates intervention to prevent or resolve
disease or illness or to promote coping and wellness
What are the guidelines for composing a nursing diagnosis
statement?
· Phrase diagnostic statement as an actual or potential diagnosis,
problem, or issue
· Check to make sure that the problem precedes etiology
· Consider when at risk populations or associated conditions
should be identified
· Signs and symptoms should follow etiology
· Write in legally advisable terms
· Use non judgmental language
· Problem statement should indicate what is unhealthy about the
patient or what patient wants to change
· Avoid using defining characteristics, medical diagnoses or
something that cannot be changed in problem statement
· Reread diagnosis to make sure that the problem statement
suggests patient outcomes and that etiology will direct selection
of nursing measures
,three components of problem focused nursing statement
problem, cause, signs/symptoms
problem
describes health state or healthy problem as clearly and concise
as possible
identifies what it healthy about patient, what patient wants to
change
cause/etiology
factors that are maintaining unhealthy patient state
suggests appropriate nursing measures
physiological, psychological, sociological, spiritual,
environmental
signs and symptoms
subjective and objective data that signal existence of a problem
(cue)suggest evaluative criteria
Review and define what is meant by a "risk nursing diagnosis"
Risk nursing diagnosis= clinical judgement concerning the
vulnerability of an individual, family, group or community for
developing an undesirable human response to health
conditions/life processes
problem-focused nursing diagnosis
a clinical judgment concerning an undesirable human response
to a health condition/ life process that exists in an individual,
family or community
, health promotion diagnosis
a concern with which a healthy person desires nursing assistance
to maintain or achieve a higher level of wellness
Why would you want to be cautious when documenting that a
patient is non-compliant and hostile in their chart
Things to consider Multiple factors may underlie the client's
response to education in a complex and emotionally charged
situation, such as receiving a new ostomy. As a result, it is likely
presumptuous to ascribe the client's response to hostility.
common sources of misdiagnosis
o Premature diagnosis based on incomplete database.
o Erroneous diagnoses resulting from an inaccurate database or
faulty data analysis.
o Routine diagnoses resulting from the nurse's failure to tailor
data collection and analysis to the unique needs of the patient.
o Errors of omission (failure to modify)
When writing a nursing diagnosis review the importance of
validation
- Computers cannot replace humans and critical thinking, you
will need to validate your diagnostic statements and recognize
when your computer is making an obvious error
· Is my patient database sufficient, accurate and supported by
nursing research
· Does my synthesis of data demonstrate pattern existence
· Is my tentative problem statement based on scientific nursing
knowledge and clinical expertise
