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. Choice b is an example of using an insufficient number of cues, an error in interpretation. Choice c is an example of not accurately identifying the problem, a labeling error. Choice d is an example of not incorporating cultural information into the diagnostic process, an error in interpretation. Choice e is an example of incorrect clustering, a clustering error.
9. Answer: 1, 2, 4.
Diagnosis 1 uses a medical diagnosis as a related factor. Diagnosis 2 uses a clinical sign rather than a treatable etiology such as “excess noise in environment.” Diagnosis 4 uses a diagnostic study as the etiology. None of the etiologies can be managed or treated by nursing intervention.
10. Answer: 2, 4, 5.
The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem.
11. Answer: The best way to understand the answer to this question is to have a list of NANDA-I nursing diagnoses and their defining characteristics. For example, the nursing diagnosis of constipation is a possible choice. Examples of additional defining characteristics for which the nurse might assess include checking the quality of bowel sounds, palpating the abdomen for a possible mass, observing the character of any stool that is passed, asking the patient if she is passing flatus.
12. Answer: 2, 3, 5.
Pacing, getting lost, and hyperactivity are a cluster of defining characteristics that point to the diagnostic label of wandering.
13. Answer: 2, 3.
Hemorrhage and wound infection are collaborative problems, actual or potential physiological complications. Nurses typically monitor for these to detect changes in a patient’s status. Nausea and fear are both NANDA-I approved nursing diagnoses.
14. Answer: 3.
Answer 3 is an accurate NANDA-I approved nursing diagnosis with an appropriate etiology. Answer 1 is a goal with an etiologic factor. Answer 2 is a goal with a diagnostic statement. Answer 4 is a nursing diagnostic label with a clinical sign.
15. Answer: 1.
A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.