Evolution of Nursing Diagnosis

Every question here, with the answer

1. A nurse is caring for a patient with type 2 diabetes mellitus and wants to move from a medical diagnosis to a nursing diagnosis that can guide an individualized plan of care. Which statement best reflects the nursing diagnosis approach described in the section?

   1. The provider will determine the patient’s glucose problem.
   2. Risk for unstable blood glucose levels related to insufficient diabetes management.
   3. The patient has type 2 diabetes mellitus.
   4. The patient is a diabetic.

   Answer: Risk for unstable blood glucose levels related to insufficient diabetes management.

   The correct option changes a broad medical description into a patient-focused nursing diagnosis that identifies a specific need and a potential cause. The other options either label the patient, state only the medical diagnosis, or shift the nurse’s decision-making role away from nursing diagnosis.

2. A nurse has implemented a care plan and is now evaluating whether the plan should continue, be modified, or be discontinued. Which questions are appropriate for the nurse to ask during this evaluation step? Select all that apply.

   1. Does anything about the plan need to be changed?
   2. Is the patient making progress toward the intended results?
   3. Was the goal met—fully, partially, or not at all?
   4. Can the plan continue as planned?
   5. Which domain and class should be assigned before any evaluation occurs?

   Answer: Does anything about the plan need to be changed?, Is the patient making progress toward the intended results?, Was the goal met—fully, partially, or not at all?, Can the plan continue as planned?

   Evaluation focuses on the patient’s progress toward the desired outcome and whether the plan should continue, change, or stop. Assigning a domain and class is related to organizing nursing diagnoses, not evaluating the effectiveness of an implemented plan.

3. A nurse enters a room after a vital sign monitor alarms. The patient is pale, diaphoretic, sitting in a tripod position, and says, “I can’t catch my breath, and my chest hurts.” Which priority hypothesis best reflects the CJMM approach in this acute situation?

   1. The patient’s comfort domain should be classified before deciding what to do.
   2. The patient may have acute respiratory distress or cardiac compromise.
   3. The patient’s primary issue is that the plan of care needs more time to work.
   4. The patient should first be evaluated for readiness to learn.

   Answer: The patient may have acute respiratory distress or cardiac compromise.

   In an acute situation, the nurse prioritizes breathing and circulation concerns using the ABCs framework. The other options delay priority thinking or focus on classification, time, or teaching rather than the urgent cues described.

4. A nurse is planning care for a patient and wants to include the patient’s support network as described in the nursing process. Which people may appropriately be included as part of this collaborative process? Select all that apply.

   1. Family members
   2. Only the nurse, because nursing diagnosis is an autonomous function
   3. Friends
   4. Loved ones
   5. Significant others

   Answer: Family members, Friends, Loved ones, Significant others

   The section emphasizes that nurses consider not only the patient but also others involved in care and support. Limiting the process to only the nurse ignores the collaborative role of the patient’s support network.

5. A new nurse is caring for a complex patient whose condition changes unexpectedly and does not fit neatly into a ready-made diagnosis. Which framework best supports the nurse in dynamically revising the nursing diagnosis through critical thinking and clinical judgment?

   1. The Clinical Judgment Measurement Model, because it supports flexible clinical judgment for changing patient needs.
   2. NANDA-I only, because ready-made diagnoses always fit complex patient needs.
   3. Taxonomy II only, because arranging diagnoses alphabetically solves unexpected changes.
   4. The ANA Standards of Practice, because they eliminate the need to revise nursing diagnoses.

   Answer: The Clinical Judgment Measurement Model, because it supports flexible clinical judgment for changing patient needs.

   The section explains that complex and unexpected patient changes require nurses to think critically and revise nursing diagnoses dynamically, leading to the CJMM. The other options overstate or misapply NANDA-I, Taxonomy II, or ANA standards.

6. A nurse has collected patient data and is using the CJMM skill of Analyze Cues. Which actions match this cognitive skill? Select all that apply.

   1. Recognizing patterns in the clinical data
   2. Determining whether patient outcomes were fully or partially met
   3. Interpreting collected data using an existing knowledge base
   4. Organizing the clinical data
   5. Generating hypotheses regarding the clinical cues collected

   Answer: Recognizing patterns in the clinical data, Interpreting collected data using an existing knowledge base, Organizing the clinical data, Generating hypotheses regarding the clinical cues collected

   Analyze Cues involves interpreting and organizing collected data, recognizing patterns, and generating hypotheses. Determining whether outcomes were met belongs to Evaluate Outcomes, not Analyze Cues.