Question: 26 UNIT NURSING DATA COLLECTION DOCUMENTATION, AND ANALYSIS 2. Before The Nurse Analyzes The Data Collected, The Nurse Should A Determine Collaborative Problems With The Health Care Learn. Group The Data Into Clusters Or Groups Of Problems. Generate Possible Hypotheses For The Client’s Problems D. Perform The Steps Of The Assessment Process Accurately …

26 UNIT NURSING DATA COLLECTION DOCUMENTATION, AND ANALYSIS 2. Before the nurse analyzes the data collected, the nurse should a determine collaborative problems with the health care learn. group the data into clusters or groups of problems. generate possible hypotheses for the client’s problems d. perform the steps of the assessment process accurately 1. The nurse is caring for an adult client who tells the nurse “For weeks now, I’ve been so tired. I just can get to sleep at night because of all the noise in my neighborhood. An actual nursing diagnosis for this client is a fatigue related to excessive noise levels as manifested by the client’s statements of chronic fatigue b. sleep deprivation related to noty neighborhood and inability to sleep. chronic fatigue syndrome related to excessive levels of noise in neighborhood. d. readiness for enhanced sleep related to control of noise level in the home. 4. A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to a formulate too many nursing diagnoses for the client and family b. Include too much data about the client in the history cobtain an insufficient number of cues and cluster patterns d. quickly make a diagnosis without hypothesizing several diagnoses. 5. When formulating a nursing diagnosis, the format that is most useful to clearly document the client’s problem is a. NANDA label (for problem) + related to etiology AMB (as manifested by) + defining characteristics b. NANDA label + defining characteristics + AMB (as manifested by the etiology. NANDA label + definition defining characteristics – AMB (as manifested by) etiology d. NANDA label definition + etiology + AMS (as manifested by) – defining characteristics. 6. Select the following nursing diagnosis that is correctly stated. a. Risk for Impaired Skin Integrity related to immobility, bedrest, pain in legs, and the client states “I will not go to Physical therapy.” Risk for Impaired Skin Integrity related to immobility as manifested by constant bedrest and the Inability to ambulate the client twice a day. Risk for Impaired Skin Integrity related to immobility secondary to right-sided paralysis, dehydration, and reluctance to participate in physical therapy as manifested by reddened Coccyx and very dry skin. d. Risk for Impaired Skin Integrity related to bedrest, lack of time to ambulate client, right-sided paralysis, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin. 7. Which of the following sequences describes the correct order of steps for analyzing data? a. Identify abnormal data and strengths, cluster data, draw inferences, propose possible nursing diagnoses, check for the presence of defining characteristics, confirm or rule out nursing diagnoses, document conclusions b. Identify abnormal data and strengths cluster data, draw inferences, check for the presence of defining characteristics, propose possible nursing diagnoses, confirm or rule out nursing diagnoses, document conclusions. Identify abnormal data and strengths, draw Inferences, chaster data, check for the presence of defining characteristics, propose possible nursing diagnoses, confirm or rule out nursing diagnoses, document conclusions. d. Identity abnormal data and strengths, draw inferences, cluster data, check for the presence of defining characteristics, confirm or rule out nursing diagnoses, propose possible nursing diagnoses, document conclusions. 27 CHAPTER 5 THINKING CRITICALLY TO ANALYZE DATA AND MAKE INFORMED NURSING JUDGMENTS 8. Which of the following is a collaborative problem? a. Risk for skin breakdown b. Risk for osteoporosis C. Risk for stress d. Risk for rape trauma syndrome C CTIVITY mnmnlains of difficulty fixing