Nursing Assessment
Potter: Fundamentals of Nursing, 8th Edition
Chapter 17: Nursing Diagnosis
Answer Key - Review Questions and Rationales
1. Answer: P, acute pain; E, related to incisional trauma; S, evidenced by pain reported at 7, with guarding, and restricted turning and positioning. The PES format stands for: P (problem), E (etiology or related factor), and S (symptoms or defining characteristics).
2. Answer: 1, 4.
Answer 1 is stated correctly, with the related factor being the patient’s response to a health problem. Answer 4, risk for infection, is a risk factor for an at-risk diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventive measures. Answer 2 is incorrect since chronic emphysema is a medical diagnosis. Answer 3 is not a NANDA-I–approved nursing diagnosis.
3. Answer: 3.
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.
4. Answer: 3.
A patient’s readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient’s motivation and desire to strengthen his health.
5. Answer: 3, 4.
In answer 3 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 answer 4 the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. In answer 1 the nurse validates findings to make an accurate diagnosis. In answer 2 the nurse interprets cue clusters to make an accurate diagnosis.
6. Answer: 4.
In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.
7. Answer: 2, 3, 4, 1.
8. Answer: 1 a, 2 b and d, 3 e, 4 c.
Choice a is an example of lack of skill, an error in collecting data.
Chapter 17: Nursing Diagnosis
Answer Key - Review Questions and Rationales
1. Answer: P, acute pain; E, related to incisional trauma; S, evidenced by pain reported at 7, with guarding, and restricted turning and positioning. The PES format stands for: P (problem), E (etiology or related factor), and S (symptoms or defining characteristics).
2. Answer: 1, 4.
Answer 1 is stated correctly, with the related factor being the patient’s response to a health problem. Answer 4, risk for infection, is a risk factor for an at-risk diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventive measures. Answer 2 is incorrect since chronic emphysema is a medical diagnosis. Answer 3 is not a NANDA-I–approved nursing diagnosis.
3. Answer: 3.
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.
4. Answer: 3.
A patient’s readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient’s motivation and desire to strengthen his health.
5. Answer: 3, 4.
In answer 3 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 answer 4 the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. In answer 1 the nurse validates findings to make an accurate diagnosis. In answer 2 the nurse interprets cue clusters to make an accurate diagnosis.
6. Answer: 4.
In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.
7. Answer: 2, 3, 4, 1.
8. Answer: 1 a, 2 b and d, 3 e, 4 c.
Choice a is an example of lack of skill, an error in collecting data.