The nurse completes a health and physical assessment on a patient admitted with a fractured pelvis. Which of the following tasks should the nurse do next?
a. Analyze and cluster the assessment information.
b. Formulate a nursing diagnosis addressing actual issues.
c. Determine the need for potential nursing diagnoses.
d. Create health promotion diagnoses for the patient.
ANS: A
Nursing diagnosis is the second step of the nursing process. Formulation of nursing diagnoses follows patient data collection and involves the analysis and clustering of related assessment information. Actual nursing diagnoses identify existing problems or concerns of a patient. Risk nursing diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication. Health-promotion nursing diagnoses are used in situations in which patients express interest in improving their health status through a positive change in behavior. The analysis of information is required to determine nursing diagnoses.
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