The nurse is developing a plan of care for a patient with gastritis and an inflammation of the intestines. The patient is complaining of severe abdominal discomfort and nausea

Question

The patient also reports having restless leg syndrome and an inability to urinate. As a problem statement of the nursing diagnosis, the nurse should write:
a.
Gastritis related to inflammation.
b.
Alterations in comfort and ability to void.
c.
Abdominal pain and nausea related to inflammation.
d.
Alteration in comfort related to restless leg syndrome and inflammation.

Answer 1

ANS: C
One patient may have several problems simultaneously, requiring the nurse to understand the potential relatedness of signs and symptoms from various body systems. The nurse combines an understanding of pathophysiology, normal structure and function, disease processes, and symptomatology to accurately cluster data. A variety of errors in identification, statement structure, and statement content may occur when formulating nursing diagnoses. These include clustering unrelated data (as with the alteration in comfort and the ability to void), accepting erroneous data, using medical diagnoses as related factors in the nursing diagnostic statement (gastritis is a medical diagnosis), missing the true underlying etiology of a problem, and identifying multiple nursing diagnosis labels in one nursing diagnostic statement. Clustering unrelated data (such as restless leg syndrome and inflammation) most often occurs when the nurse has not completed a thorough review of the patient's assessment information or is missing important data. Regardless of the type of nursing diagnosis being written, only one label should be used in each statement. Abdominal pain and nausea, in this case, have the same cause, so clustering is proper.