The nurse in an outpatient clinic obtains a blood pressure of 190/88 mm Hg on a patient diagnosed with high blood pressure. The patient tells the nurse, "My blood pressure medicine is really expensive
Do you think I really need it?" The nurse assumes the patient is not taking the medication based on the blood pressure result and the patient's statement and chooses noncompliance as a diagnostic label. The action by the nurse is an example of:
a.
clustering unrelated data in the diagnostic statement.
b.
selecting erroneous data for use in the diagnostic statement.
c.
using medical diagnoses in the diagnostic statement.
d.
identifying multiple problems within one diagnostic statement.
ANS: A
A variety of errors in identification, statement structure, and statement content may occur when formulating nursing diagnoses. These include clustering unrelated data, accepting erroneous data, using medical diagnoses as related factors in the nursing diagnostic statement, missing the true underlying etiology of a problem, and identifying multiple nursing diagnosis labels in one nursing diagnostic statement. Clustering unrelated data most often occurs when the nurse has not completed a thorough review of the patient's assessment information or is missing important data. The nurse assumes the patient is not taking the blood pressure medication because of the cost and chooses the diagnosis of noncompliance. The nurse fails to ask the patient if the medication is being taken as ordered. Errors in data collection (e.g., omitting key information) or an incomplete understanding or knowledge of assessment techniques or a patient's condition may lead to the inclusion of erroneous data in a nursing diagnostic statement. When writing nursing diagnoses, the nurse should avoid inclusion of more than one label in the statement. Regardless of the type of nursing diagnosis being written, only one label should be used in each statement. The nurse does not commit this error here. "Noncompliance" is not a medical diagnosis.
You might also like to view...
The nurse is concerned that an older patient has undiagnosed sleep apnea and is at risk for which additional health problem?
1. Underweight 2. Excessive deep sleep 3. Increased risk for sudden death and stroke 4. Excessive tension in the muscles of the throat and soft palate
Which of the following is the best example of an outcome statement? The patient will:
1) Use the incentive spirometer when awake. 2) Walk two times during day and evening shift. 3) Maintain an oxygen saturation above 92% while performing ADLs each morning. 4) Tolerate 10 sets of range-of-motion exercises with physical therapy.
On the basis of the changing demographics of the United States, which of the following services are likely to consume an increasing percentage of the national expenditures for health care?
1. services for pregnant teenagers 2. long-term care for the elderly 3. treatment of the leading causes of illness for whites 4. services to Native-Americans
Why is it necessary for nurses to obtain certification?
a. To assure competence at an advanced level b. To verify minimal competency levels of practice c. To create a network for nurses to collaborate d. To make it difficult to become a nurse