A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency
department. The nurse collects a nursing history and interviews the patient. Place the following steps for
making a nursing diagnosis in the correct order.
_____ 1. Considers context of patient's health problem and selects a related factor
_____ 2. Reviews assessment data, noting objective and subjective clinical criteria
_____ 3. Clusters clinical criteria that form a pattern
_____ 4. Chooses diagnostic label - ansCorrect Answer(s):
2, 3, 4, 1
A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing
diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best
described as:
A) Identifying the clinical sign instead of an etiology.
B) Identifying a diagnosis based on prejudicial judgment.
C) Identifying the diagnostic study rather than a problem caused by the diagnostic study.
D) Identifying the medical diagnosis instead of the patient's response to the diagnosis. - ansCorrect Answer(s):
D
In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.
A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining
characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct
diagnosis. This is an example of the nurse avoiding an error in:
A) Data collection.
B) Data clustering.
C) Data interpretation.
D) Making a diagnostic statement. - ansCorrect Answer(s): C
, In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects
one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not
included a related factor.
In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.)
A) The nurse who listens to lung sounds after a patient reports "difficulty breathing"
B) The nurse who considers conflicting cues in deciding which diagnostic label to choose
C) The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema
D) The nurse who identifies a diagnosis on the basis of a single defining characteristic - ansCorrect Answer(s): C,
D
When the nurse assesses edema without knowing how to assess the severity, the nurse fails to validate her
assessment findings of edema, either by using a scale to measure the severity or by asking a colleague to
validate her findings. In identifying a diagnosis on the basis of a single defining characteristic, the nurse
prematurely closes clustering, which can lead to an inaccurate diagnosis. By listening to lung sounds after the
patient reports "difficulty breathing" the nurse validates findings to make an accurate diagnosis. The nurse
interprets cue clusters to make an accurate diagnosis when considering conflicting cues to make a diagnosis.
Match the activity on the left with the source of diagnostic error on the right:
Activity
a. Nurse listens to lungs for first time and is not sure if abnormal lung sounds are present.
b. After reviewing objective data, nurse selects diagnosis of fear before asking patient to discuss feelings.
c. Nurse identifies incorrect diagnostic label.
d. Nurse does not consider patient's cultural background when reviewing cues.
e. Nurse prepares to complete decision on diagnosis and realizes that clinical criteria are grouped incorrectly to
form a pattern.
Source of Diagnostic Error
__ 1. Collecting data
__ 2. Interpreting
__ 3. Clustering