The nurse formulates nursing diagnoses for a client with chronic ...

[Awilson837]

The nurse formulates nursing diagnoses for a client with chronic renal failure. Which statements indicate the nurse appropriately used a two-part format?
 
  1. Pruritis related to toxin build-up in the blood
  2. Hypertension related to fluid volume overload
  3. Deficient fluid volume related to fluid restriction
  4. Personal care challenges related to fistula in left arm
  5. Acute confusion related to delayed hemodialysis treatment

Question 2

The nurse is using the PES model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately?
 
  1. Ineffective coping related to depression as evidenced by suicide attempt
  2. Noncompliance (DASH diet) related to denial of having disease
  3. Risk for infection related to recent surgery
  4. Nutrition less than adequate related to anxiety as evidenced by weight loss of ten pounds
  5. Ineffective Breathing Pattern as evidenced by cyanotic lips

[chloejackso]

Answer to Question 1

Answer: 3, 5

Rationale 1: The nursing diagnosis should not include medical diagnoses such as pruritis.

Rationale 2: The nursing diagnosis should not include medical diagnoses such as hypertension.

Rationale 3: The nursing diagnosis should include a problem statement, such as deficient fluid volume, and the etiology, which is fluid restriction. These two parts are connected by the phrase related to.

Rationale 4: A personal care challenge is not a nursing diagnostic problem.

Rationale 5: The nursing diagnosis should include a problem statement, such as acute confusion, and the etiology, which is delayed hemodialysis treatment. These two parts are connected by the phrase related to.

Answer to Question 2

Correct Answer: 1, 4
Rationale: The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms.

[Awilson837]

TYSM

[tkempin]

Excellent