Categories of Nursing Diagnosis

Every question here, with the answer

1. An older adult lives alone and reports vertigo. The patient has not fallen, but the nurse is concerned about what could happen without preventive interventions. Which category of nursing diagnosis best fits this situation?

   1. Problem-focused diagnosis
   2. Syndrome diagnosis
   3. Risk diagnosis
   4. Health promotion diagnosis

   Answer: Risk diagnosis

   A risk diagnosis is used when the nurse identifies a potential problem that may develop if no intervention is started. This patient has not fallen, so a problem-focused diagnosis based on actual signs and symptoms of a fall would not fit; health promotion and syndrome diagnoses do not match this specific potential safety problem.

2. A nurse is validating a newly selected nursing diagnosis for a patient. Which actions or questions are appropriate during validation? Select all that apply.

   1. Use the electronic health record suggestion without taking any additional validation steps.
   2. Encourage the patient’s ongoing participation and ask about the patient’s perceptions of the problem.
   3. Determine whether the collected assessment data are appropriate, accurate, and supported by nursing research.
   4. Select the diagnosis only because it matches the medical diagnosis.
   5. Ask whether other qualified clinicians would formulate the same nursing diagnosis based on the data.

   Answer: Encourage the patient’s ongoing participation and ask about the patient’s perceptions of the problem., Determine whether the collected assessment data are appropriate, accurate, and supported by nursing research., Ask whether other qualified clinicians would formulate the same nursing diagnosis based on the data.

   Validation requires evidence-based confirmation that the diagnosis fits the individual patient, including accurate assessment data, consistency with how other qualified clinicians would interpret the data, and patient participation. The section emphasizes that electronic tools may help identify diagnoses, but the nurse must still manually validate the diagnosis; it also differentiates nursing diagnoses from medical diagnoses.

3. A patient says, “I want to start exercising regularly because I want to improve my overall health.” Which nursing diagnosis category is most appropriate?

   1. Problem-focused diagnosis
   2. Health promotion diagnosis
   3. Risk diagnosis
   4. Syndrome diagnosis

   Answer: Health promotion diagnosis

   This situation focuses on the patient’s motivation and desire to improve well-being, which fits a health promotion diagnosis. There is no actual problem with signs and symptoms, no stated potential risk, and no cluster of diagnoses tied to a life event or situation.

4. A nurse is formulating the diagnosis “ineffective breathing pattern related to decreased lung expansion as evidenced by dyspnea, coughing, and difficulty breathing.” Which findings are defining characteristics in this diagnosis? Select all that apply.

   1. Coughing
   2. Difficulty breathing
   3. Decreased lung expansion
   4. Ineffective breathing pattern
   5. Dyspnea

   Answer: Coughing, Difficulty breathing, Dyspnea

   Defining characteristics are the actual signs and symptoms and are written after “as evidenced by.” In this diagnosis, decreased lung expansion is the related factor, and ineffective breathing pattern is the identified problem or label, not a defining characteristic.

5. A patient has the nursing diagnosis “ineffective breathing pattern related to decreased lung expansion as evidenced by dyspnea, coughing, and difficulty breathing.” After interventions are implemented, the patient continues to have the same signs and symptoms. What should the nurse do next?

   1. Keep the same diagnosis because interventions were already implemented.
   2. Change the diagnosis to a health promotion diagnosis because treatment has started.
   3. Refine the nursing diagnosis and consider a more specific underlying cause of the problem.
   4. Remove the nursing diagnosis because the patient did not improve.

   Answer: Refine the nursing diagnosis and consider a more specific underlying cause of the problem.

   When outcomes show that the patient continues to display the same signs and symptoms, the nurse should reassess and refine the diagnosis. The section describes considering further diagnostic tests and a more specific underlying cause rather than simply keeping, removing, or changing the diagnosis to an unrelated category.

6. A nurse is caring for a patient who experienced a traumatic event. The nurse is considering a syndrome diagnosis. Which statements reflect appropriate use of a syndrome diagnosis? Select all that apply.

   1. It may identify several potential nursing diagnoses based on a specific life event.
   2. It can include actual, risk, or health promotion diagnoses that are commonly used for the patient’s situation.
   3. It replaces the need to consider the patient’s signs, symptoms, or situation.
   4. The nurse must ensure the diagnosis still relates to the individual patient.
   5. It should be used as a “one-and-done” tactic once the event is identified.

   Answer: It may identify several potential nursing diagnoses based on a specific life event., It can include actual, risk, or health promotion diagnoses that are commonly used for the patient’s situation., The nurse must ensure the diagnosis still relates to the individual patient.

   A syndrome diagnosis is used when a cluster of nursing diagnoses may apply based on life events or situations, and it can include actual, risk, or health promotion diagnoses. The nurse still must individualize the diagnosis; it is not a one-time label and does not replace assessment of the patient’s situation.