Which one of the following sets of assessment data is most likely to be present with the nursing diagnosis Risk for infection?
1. fever, dysuria, change in urine concentration, and urinary urgency
2. abdominal pain, sore mouth, hyperactive bowel sounds, and leukopenia
3. fatigue, electrocardiographi c changes, dependent edema, and activity intolerance
4. abdominal incision, decreased hemoglobin, and indwelling catheter present
Question 2
Which of the following is the correct sequence of steps in making a nursing diagnosis?
1. Generate hypotheses about possible nursing diagnoses, check for defining characteristics, cluster assessment data into meaningful sets, choose the appropriate diagnostic label, and determine the etiology.
2. Compare cue clusters with assessment data, generate differential diagnoses, determine the etiology, make the diagnosis, plan interventions, and write the related to statement.
3. Review the assessment data, cluster the data into meaningful sets, compare clusters with defining characteristics of possible diagnoses, choose the appropriate nursing diagnosis, determine the etiology, and write the related to statement.
4. Cluster data into meaningful sets, choose the appropriate nursing diagnosis, compare diagnosis with assessment data, determine the etiology, plan interventions, and write the related to statement.
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