Nursing 204 Exam 2 notes Questions
With Complete Solutions Rated A+
when does the assessment process begin?
what is the next step? - CORRECT ANSWER-- initial meeting between nurse and client/
family
- obtain information about the client's current and past problems
in addition to your interview, assessment includes information you obtain from: -
CORRECT ANSWER-existing records, past diagnostic testing, information from family,
and in some instances, contact with previous health care providers, schools, or other
referral sources
objective data - CORRECT ANSWER-(observed)
- data directly observed or verified through physical exams or tests
- document specific, measurable terms
nursing diagnosis - CORRECT ANSWER-- a comprehensive biopsychosocial statement
that captures the essence of the client's health care needs/ problems
- describes the client's human responses to health issues and medical diagnoses
subjective data - CORRECT ANSWER-(stated)
- client's perception of data and what client or family says about the data
types of nursing diagnosis - CORRECT ANSWER-problem- focused
risk and high- risk
,possible
health promotion
syndrome
problem- focused nursing diagnosis (4 components) - CORRECT ANSWER-- human
response to health conditions/ life processes that can exist in an individual, family, or
community
- supported by defining characteristics that cluster in patterns of related cues or
inferences
components:
label, definition, defining characteristics, and related factors
label for problem- focused ND - CORRECT ANSWER-the label should be clear, concise
terms that convey the meaning of the diagnosis
definition for problem- focused ND - CORRECT ANSWER-- the definition should add
clarity to the diagnostic label
- it should also help to differentiate a particular diagnosis from similar diagnosis
defining characteristics of problem- focused ND - CORRECT ANSWER-- signs and
symptoms that, when seen together, represent the nursing diagnosis (major and minor)
related factors of problem- focused ND (4 categories) - CORRECT ANSWER-- related
factors are contributing factors that have influenced the change in health status
4 categories:
- pathophysiologic, biologic, or psychological
- treatment- related
- situational
, - maturational
Risk and High Risk Nursing Diagnosis - CORRECT ANSWER-- human response to
health conditions/ life processes that may develop in a vulnerable individual, family, or
community
- supported by risk factors that contribute to increased vulnerability: risk and high risk
risk - CORRECT ANSWER-expected or predictive diagnoses for all individuals who are
undergoing some situation
high- risk - CORRECT ANSWER-for people with additional risk factors that may be
more vulnerable for the problem to occur
Possible Nursing Diagnosis - CORRECT ANSWER-- describe a suspected problem
requiring additional data to confirm or rule out
- nurse can confirm presence of major signs and symptoms and label as problem
focused ND or
- nurse can confirm presence of potential risk factors and label as Risk ND or
- nurse can rule out presence of diagnosis at this time
Health- Promotion Nursing Diagnosis (2 cues) - CORRECT ANSWER-- a clinical
judgment of a person's, family's or community's motivation and desire to increase well-
being and actualize human health potential as expressed in the readiness to enhance
specific health behaviors, such as nutrition and exercise
2 cues:
- a desire for increased wellness
- effective present status or function in the specific health behavior
With Complete Solutions Rated A+
when does the assessment process begin?
what is the next step? - CORRECT ANSWER-- initial meeting between nurse and client/
family
- obtain information about the client's current and past problems
in addition to your interview, assessment includes information you obtain from: -
CORRECT ANSWER-existing records, past diagnostic testing, information from family,
and in some instances, contact with previous health care providers, schools, or other
referral sources
objective data - CORRECT ANSWER-(observed)
- data directly observed or verified through physical exams or tests
- document specific, measurable terms
nursing diagnosis - CORRECT ANSWER-- a comprehensive biopsychosocial statement
that captures the essence of the client's health care needs/ problems
- describes the client's human responses to health issues and medical diagnoses
subjective data - CORRECT ANSWER-(stated)
- client's perception of data and what client or family says about the data
types of nursing diagnosis - CORRECT ANSWER-problem- focused
risk and high- risk
,possible
health promotion
syndrome
problem- focused nursing diagnosis (4 components) - CORRECT ANSWER-- human
response to health conditions/ life processes that can exist in an individual, family, or
community
- supported by defining characteristics that cluster in patterns of related cues or
inferences
components:
label, definition, defining characteristics, and related factors
label for problem- focused ND - CORRECT ANSWER-the label should be clear, concise
terms that convey the meaning of the diagnosis
definition for problem- focused ND - CORRECT ANSWER-- the definition should add
clarity to the diagnostic label
- it should also help to differentiate a particular diagnosis from similar diagnosis
defining characteristics of problem- focused ND - CORRECT ANSWER-- signs and
symptoms that, when seen together, represent the nursing diagnosis (major and minor)
related factors of problem- focused ND (4 categories) - CORRECT ANSWER-- related
factors are contributing factors that have influenced the change in health status
4 categories:
- pathophysiologic, biologic, or psychological
- treatment- related
- situational
, - maturational
Risk and High Risk Nursing Diagnosis - CORRECT ANSWER-- human response to
health conditions/ life processes that may develop in a vulnerable individual, family, or
community
- supported by risk factors that contribute to increased vulnerability: risk and high risk
risk - CORRECT ANSWER-expected or predictive diagnoses for all individuals who are
undergoing some situation
high- risk - CORRECT ANSWER-for people with additional risk factors that may be
more vulnerable for the problem to occur
Possible Nursing Diagnosis - CORRECT ANSWER-- describe a suspected problem
requiring additional data to confirm or rule out
- nurse can confirm presence of major signs and symptoms and label as problem
focused ND or
- nurse can confirm presence of potential risk factors and label as Risk ND or
- nurse can rule out presence of diagnosis at this time
Health- Promotion Nursing Diagnosis (2 cues) - CORRECT ANSWER-- a clinical
judgment of a person's, family's or community's motivation and desire to increase well-
being and actualize human health potential as expressed in the readiness to enhance
specific health behaviors, such as nutrition and exercise
2 cues:
- a desire for increased wellness
- effective present status or function in the specific health behavior
