A nurse is assessing a client who has a fever and reports feeling cold. The nurse observes that the client is shivering and has goosebumps on his skin. Which of the following terms should the nurse use to describe these findings in the diagnostic statement?
Problem.
Etiology.
Defining characteristics.
Related factors.
The Correct Answer is C
Choice A reason:.
Problem is not the correct term to describe these findings because it is too vague and does not specify the human response to the health condition. A problem is a general label that can apply to many situations, but a nursing diagnosis should be more precise and descriptive.
Choice B reason:.
Etiology is not the correct term to describe these findings because it refers to the cause or contributing factors of the problem, not the problem itself. Etiology is usually preceded by the phrase "related to”. in a nursing diagnostic statement. For example, "Impaired skin integrity related to pressure ulcer”. is a nursing diagnosis where "pressure ulcer”. is the etiology.
Choice C reason:.
Defining characteristics is the correct term to describe these findings because it refers to the observable and verifiable signs and symptoms that indicate the presence of a problem or risk. Defining characteristics are usually preceded by the phrase "as evidenced by”. in a nursing diagnostic statement. For example, "Acute pain as evidenced by grimacing, guarding, and increased heart rate”. is a nursing diagnosis where "grimacing, guarding, and increased heart rate”. are the defining characteristics.
Choice D reason:.
Related factors is not the correct term to describe these findings because it refers to the conditions or circumstances that are associated with the problem or risk, but are not necessarily the cause. Related factors are usually preceded by the phrase "related to”. in a risk nursing diagnostic statement. For example, "Risk for falls related to impaired balance”. is a nursing diagnosis where "impaired balance”. is a related factor.
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Related Questions
Correct Answer is B
Explanation
Choice A reason:.
This is not an example of an actual diagnosis because it describes a potential problem that has not yet occurred. An actual diagnosis identifies a problem that is present at the time of the assessment and is based on signs and symptoms.
Choice B reason:.
This is an example of an actual diagnosis because it describes a problem that is present at the time of the assessment and is based on signs and symptoms. An actual diagnosis consists of three components: the problem, the etiology, and the defining characteristics. In this case, the problem is impaired skin integrity, the etiology is related to pressure ulcer, and the defining characteristics are evidenced by 4 cm x 3 cm wound on sacrum.
Choice C reason:.
This is not an example of an actual diagnosis because it does not include any defining characteristics that support the problem. An actual diagnosis requires evidence of signs and symptoms to validate the problem.
Choice D reason:.
This is not an example of an actual diagnosis because it describes a readiness to enhance a specific health behavior rather than a problem that is present at the time of the assessment. A readiness for enhanced diagnosis identifies a strength or potential for improvement in a client's health status.
Correct Answer is B
Explanation
Choice A reason:
An actual diagnosis is based on the presence of associated signs and symptoms, not on the risk of developing them. The client in the question does not have any signs or symptoms of withdrawal yet, only a history of substance abuse. Therefore, an actual diagnosis is not appropriate for this client.
Choice B reason:
A risk diagnosis is based on the presence of risk factors that increase the likelihood of developing a problem or dysfunction. The client in the question has a history of substance abuse, which is a risk factor for withdrawal. The nurse plans to monitor the client for signs of anxiety, agitation, and tremors, which are potential indicators of withdrawal. Therefore, a risk diagnosis is appropriate for this client.
Choice C reason:
A health promotion diagnosis is based on the desire to enhance well-being and human potential. The client in the question does not express any desire to improve their health or well-being, nor does the nurse plan to implement any interventions to promote health. Therefore, a health promotion diagnosis is not appropriate for this client.
Choice D reason:
A wellness diagnosis is based on the presence of a transition from one level of wellness to a higher level of wellness. The client in the question does not show any evidence of a transition or a higher level of wellness, nor does the nurse plan to facilitate any wellness activities. Therefore, a wellness diagnosis is not appropriate for this client.
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