Focus of Nursing Diagnosis

Every question here, with the answer

1. A nurse is caring for a patient with an identified problem and begins considering the best signs of recovery as well as the most dangerous signs of deterioration. Which clinical decision-making step is the nurse using?

   1. Promote
   2. Manage
   3. Predict
   4. Prevent

   Answer: Predict

   The nurse is using prediction by thinking ahead about likely complications and possible outcomes. Prevention focuses on stopping problems before they occur, management begins when a problem cannot be prevented, and promotion focuses on independence and health strategies.

2. A nurse is deciding whether a patient problem should be written as a nursing diagnosis. Which findings support that it is a nursing diagnosis rather than a medical diagnosis? Select all that apply.

   1. It requires a medical order before the expected outcome can be initiated.
   2. It is performed independently within the nurse's professional scope of practice.
   3. It can change based on the patient's response to interventions.
   4. It focuses primarily on the etiology and pathophysiology of a disease.
   5. It identifies the patient's response to health and illness-related problems.

   Answer: It is performed independently within the nurse's professional scope of practice., It can change based on the patient's response to interventions., It identifies the patient's response to health and illness-related problems.

   A nursing diagnosis focuses on the patient's response, is within the nurse's scope, and is fluid based on response to interventions. Focusing on etiology and pathophysiology describes a medical diagnosis, and needing a medical order points to a collaborative problem.

3. A nurse plans a goal for a patient after knee replacement: the patient will walk to the nurses' station and back before discharge. The nurse realizes this cannot begin until the provider writes an order for physical therapy. How should the nurse classify this issue?

   1. A nursing diagnosis because impaired mobility is present
   2. A collaborative problem because the goal cannot be initiated without a medical order
   3. An expected outcome that does not require interdisciplinary involvement
   4. A medical diagnosis because the patient had surgery

   Answer: A collaborative problem because the goal cannot be initiated without a medical order

   Because the goal requires a provider order and physical therapy involvement, it is a collaborative problem. Nursing diagnoses can be addressed independently within nursing scope, even though they may be intertwined with collaborative problems.

4. Two patients receive the same new medical diagnosis of diabetes. One patient is ashamed, keeps the diagnosis secret from family and friends, and is not coping well. Which nursing actions best reflect the section's guidance? Select all that apply.

   1. Address the patient's response to the diagnosis before beginning disease-management teaching.
   2. Focus only on the medical diagnosis because the disease is the same.
   3. Consider a nursing diagnosis such as ineffective coping.
   4. Use the same nursing diagnosis as for any other patient with diabetes.
   5. Provide education on healthy coping mechanisms and how they affect disease progression.

   Answer: Address the patient's response to the diagnosis before beginning disease-management teaching., Consider a nursing diagnosis such as ineffective coping., Provide education on healthy coping mechanisms and how they affect disease progression.

   The section emphasizes that the same medical diagnosis does not create the same nursing diagnosis for every patient. This patient's response suggests ineffective coping, so coping and support should be addressed before disease-management education.

5. A nurse is preparing discharge teaching for a patient who will need to manage a condition at home. Which action best reflects the promote step of clinical decision-making?

   1. Continue all care activities for the patient to prevent independence too early.
   2. Teach the patient how to identify signs and symptoms of potential problems.
   3. Focus teaching only on the provider's medical diagnosis.
   4. Avoid involving the patient in care decisions until recovery is complete.

   Answer: Teach the patient how to identify signs and symptoms of potential problems.

   Promotion includes encouraging healing, self-management, peak functioning, and independence. Teaching the patient to recognize potential problems empowers the patient to protect their own well-being.

6. A patient develops a problem that could not be prevented. Which nurse actions are appropriate during the management phase? Select all that apply.

   1. Ask interdisciplinary team members to collaborate on care if needed.
   2. Organize monitoring for changes in the patient's condition.
   3. Involve the patient in decision-making.
   4. Use evidence-based sources and protocols.
   5. Wait to see if the problem resolves without nursing action.

   Answer: Ask interdisciplinary team members to collaborate on care if needed., Organize monitoring for changes in the patient's condition., Involve the patient in decision-making., Use evidence-based sources and protocols.

   Management includes active interventions, collaboration when needed, and monitoring for signal changes or deterioration. Waiting for the problem to fix itself is inconsistent with the nurse's responsibility to manage the situation and prevent worsening.