The nurse applies an actual nursing diagnoses when selecting:
1. Ineffective Breathing Pattern
2. Risk of Infection
3. Readiness for Enhanced Nutrition
4. Readiness for Enhanced Family Coping
5. Anxiety
Correct Answer: 1,5
Rationale 1: An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms.
Rationale 2: A risk nursing diagnosis is a clinical judgment that a problem does not exist but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
Rationale 3: A health promotion diagnosis relates to the client's preparedness for implementing behaviors to improve their health condition. These diagnosis labels begin with the phrase "readiness for enhanced."
Rationale 4: A wellness diagnosis describes human responses to levels of wellness in an individual, family or community. These diagnosis labels begin with the phrase "readiness for enhanced."
Rationale 5: An actual diagnosis is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms.
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