A nurse is formulating a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. Which of the following components should the nurse include in the statement? (Select all that apply.).
The problem.
The etiology.
The signs and symptoms.
The medical diagnosis.
The nursing interventions.
Correct Answer : A,C
Choice A reason:
The problem is the first component of a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. The problem is the nursing diagnosis that describes the client's health status in response to the actual or potential health problem. For example, the problem could be impaired skin integrity, risk for infection, or chronic pain.
Choice B reason:
The etiology is not a component of a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. The etiology is the cause or contributing factor of the problem. For example, the etiology could be diabetes mellitus, peripheral neuropathy, or poor circulation.
Choice C reason:
The signs and symptoms are the third component of a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. The signs and symptoms are the evidence or data that support the problem. For example, the signs and symptoms could be ulceration, numbness, or tingling.
Choice D reason:.
The medical diagnosis is not a component of a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. The medical diagnosis is the identification of a disease or condition by a physician or other health care provider based on scientific criteria. For example, the medical diagnosis could be diabetes mellitus type 1 or type 2, or peripheral neuropathy.
Choice E reason:
The nursing interventions are not a component of a diagnostic statement for a client who has diabetes mellitus and peripheral neuropathy. The nursing interventions are the actions or treatments that the nurse plans and implements to address the problem. For example, the nursing interventions could be wound care, education, or medication administration
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Correct Answer is C
Explanation
Choice A reason:
An actual diagnosis is based on the presence of associated signs and symptoms of a health problem. The client does not have any signs or symptoms of a health problem related to smoking, but rather has expressed a desire to quit smoking and has taken some steps to do so.
Choice B reason:
A risk diagnosis is based on the presence of risk factors that increase the vulnerability of a person or group to develop a health problem. The client does not have any risk factors that increase his vulnerability to develop a health problem related to smoking, but rather has reduced his cigarette consumption by half and has joined a support group.
Choice C reason:
A health promotion diagnosis is based on the desire to enhance well-being and can be expressed by a readiness to enhance specific health behaviors. The client has expressed a desire to quit smoking, which is a specific health behavior that can enhance his well-being. Therefore, this is the correct type of diagnosis for this client.
Choice D reason:
A wellness diagnosis is based on the presence of potential or actual levels of wellness in an individual, family, or community that can be enhanced. The client does not have any potential or actual levels of wellness related to smoking, but rather has a desire to quit smoking and improve his health. Therefore, this is not the correct type of diagnosis for this client.
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.
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