ACT.5-Answer Sheet

ACTIVITY NO.
5
●
Name: MURIAH CARYLLE R. CARIAZO
Year level: BSN 1
Section: B
Subject: NCM 103 FUNDAMENTALS OF NURSING
COMPREHENSIVE UNDERSTANDING
Critical Thinking and the Nursing Diagnostic Process

Match the following terms that relate to diagnostic conclusions.
1 D Medical diagnosis a. Desire to increase well-being and actualize human health
2. E Collaborative problem potential
3. B Defining characteristics b. The clinical criteria or assessment findings that
4. C Actual nursing diagnosis support an actual nursing diagnosis
5 F Risk nursing diagnosis c. Describes human responses to health conditions or
6. A A Health promotion nursing diagnosis life processes that exist in an individual, family, or
community
d. Identification of a disease condition
e. Actual or potential physiological complication that is
monitored in collaboration with others
f. Human responses to health conditions that may
possibly develop in a vulnerable individual, family, or
community
7. List the purposes of the using a standard formal nursing diagnostic statement.
a. Provides a precise definition of a patient’s problem that gives nurses and other members of the health care team a
common language for understanding the patient’s needs
b. Allows nurses to communicate what they do among themselves with other health care professionals and the
public.
c. Distinguishes the nurse’s role from that of the physician or other health care provider.
d. Helps nurses focus on the scope of nursing practice.
e. Fosters the development of nursing knowledge.
f. Promotes creation of practice guidelines that reflect the essence of nursing.
Define the following components of the diagnostic reasoning process
8. Data cluster- is a set of signs or symptoms gathered during assessment that you group together in a logical way.
9. Defining characteristics- the clinical criteria that are observable and verifiable.
10. Clinical criteria- is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a
diagnostic conclusion.
11. Explain the process of identifying health problems (interpretation).

Gather the information needed, review information collected about a patient, see cues and patterns in the data, and identify the patient’s
specific health care problems.
12. To individualize a nursing diagnosis, you identify the associated related factor. Explain.
Related factor gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis therefore, A
related factor allows you to individualize a nursing diagnosis for a specific patient.
13. Define wellness nursing diagnosis.

A clinical assessment of a person, family, or community moving from one degree of wellbeing to a higher level of
wellness is known as a wellness nursing diagnosis.
Explain the following components of a nursing diagnosis.

14. Diagnostic label: is the name of the nursing diagnosis as approved by NANDA International. It describes the essence of a patient’s
response to health conditions in as few words as possible.
15. Related factor: The related factor is identified from the patient’s assessment data and is the reason the patient is displaying the
nursing diagnosis.
16. Etiology: Related factors of nursing diagnosis is always within to domain of nursing practice and condition that responds to nursing
interventions
17. PES format: a three-part nursing diagnostic label. In this case the diagnostic label consists of the NANDA-I label, the related factor,
and the defining characteristics. This approach makes a diagnosis even more patient specific. The acronym PES stands for problem,
etiology, and symptoms.
18. Identify the purpose of concept mapping a nursing diagnosis. Concept mapping organizes and links information to allow you to see
new wholes and appreciate the complexity of patient care
Sources of Diagnostic Errors

Identify the sources of error in the steps of the nursing process related to:
19. Errors in collection data:
 Lack of knowledge or skills
 Inaccurate data
 Missing data
 Disorganization
20. Errors in interpretation and analysis of data:
 Inaccurate interpretation of cues
 Failure to consider conflicting cues
 Using an insufficient number of cues
 Using unreliable or invalid cues
 Failure to consider cultural
 influences or developmental stage
21. Errors in data clustering:
 Insufficient cluster of cues
 Premature or early closure
 Incorrect clustering
22. Errors in the diagnostic labeling:
 Wrong diagnostic label selected
 Evidence that another diagnosis is more likely
 Condition a collaborative problem
 Failure to validate nursing diagnosis with patient
 Failure to seek guidance
23. State the guidelines to use to reduce errors when formulating the diagnostic statement.
1. Identify the patient’s response, not the medical diagnosis

2. Identify a NANDA-I diagnostic statement rather than the symptom. Identify nursing diagnoses from a cluster of defining
characteristics and not just a single symptom.
3. Identify a treatable etiology or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing
intervention.
4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself
5. Identify the patient response to the equipment rather than the equipment itself.
6. Identify the patient’s problems rather than your problems with nursing care.
7. Identify the patient problem rather than the nursing intervention.
24. Explain how you would document a patient’s nursing diagnoses.
Either incorporate them into the care plan or the agency's electronic health information database. Priority-ordered nursing
diagnoses should be listed, dated when they are entered, reviewed, and the priority reevaluated
REVIEW QUESTIONS Select the appropriate answer, and cite the rationale for choosing that particular answer.
25. A nursing diagnosis:
1. Identifies nursing problems
2. Is not changed during the course of a patient’s hospitalization
3. Is derived from the physician’s history and physical examination
4. Is a statement of a patient response to a health problem that requires nursing intervention
Answer: 4 Rationale: because nursing diagnosis is a clinical judgment about responses to actual and potential health
problems.
26. The first part of the nursing diagnosis statement:

1. May be stated as a medical diagnosis
2. Identifies the cause of the patient problem
3. Identifies appropriate nursing interventions
4. Identifies an actual or potential health problem
Answer: 4 Rationale: The diagnostic label effectively conveys the essence of the patient's response to the disease
27. The second part of the nursing diagnosis statement:

1. Is usually stated as a medical diagnosis
2. Identifies the expected outcomes of nursing care
3. Identifies the probable cause of the patient problem
4. Is connected to the first part of the statement with the phrase “related to”
Answer; 4 Rationale: It relates to the patient's actual or potential reaction to health issues
28. Which of the following is the correctly stated nursing diagnosis?
1. Needs to be fed related to broken right arm
2. Impaired skin integrity related to fecal incontinence
3. Abnormal breath sounds caused by weak cough reflex
4. Impaired physical mobility related to rheumatoid arthritis
Answer: 2 Rationale: the actual or probable reaction to a health concern

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ACTIVITY NO.

Critical Thinking and the Nursing Diagnostic Process

Define the following components of the diagnostic reasoning process

11. Explain the process of identifying health problems (interpretation).

13. Define wellness nursing diagnosis.

Explain the following components of a nursing diagnosis.

Sources of Diagnostic Errors

1. Identify the patient’s response, not the medical diagnosis

24. Explain how you would document a patient’s nursing diagnoses.

26. The first part of the nursing diagnosis statement:

27. The second part of the nursing diagnosis statement:

Answer: 2 Rationale: the actual or probable reaction to a health concern

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