A nurse is preparing a diagnostic statement for a client who has chronic obstructive pulmonary disease (COPD) and reports shortness of breath and fatigue with minimal exertion. Which of the following formats should the nurse use to write the statement?

PES format (problem, etiology, signs and symptoms).

PE format (problem, etiology).

PS format (problem, signs and symptoms).

ES format (etiology, signs and symptoms).

Answer and Explanation

The Correct Answer is A

Choice A reason:

The PES format (problem, etiology, signs and symptoms) is the most comprehensive and accurate way to write a nursing diagnostic statement. It identifies the nursing problem, the cause or contributing factors, and the evidence or manifestations of the problem. For example, a possible PES statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern related to chronic airway obstruction as evidenced by dyspnea, tachypnea, and use of accessory muscles.

Choice B reason:

The PE format (problem, etiology) is a two-part diagnostic statement that omits the signs and symptoms of the problem. It is less specific and does not provide enough information to guide the nursing interventions and outcomes. For example, a possible PE statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern related to chronic airway obstruction. This statement does not indicate how the problem is manifested or measured.

Choice C reason:

The PS format (problem, signs and symptoms) is a two-part diagnostic statement that omits the etiology or cause of the problem. It is less precise and does not identify the factors that contribute to or influence the problem. For example, a possible PS statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern as evidenced by dyspnea, tachypnea, and use of accessory muscles. This statement does not indicate why the problem exists or what can be done to address it.

Choice D reason:

The ES format (etiology, signs and symptoms) is a two-part diagnostic statement that omits the problem or nursing diagnosis. It is incomplete and does not state what the actual or potential health issue is. For example, a possible ES statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Chronic airway obstruction as evidenced by dyspnea, tachypnea, and use of accessory muscles. This statement does not indicate what the nursing problem is or what the desired outcome is.

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Correct Answer is A

Explanation

Choice A reason:

It involves determining the effectiveness of nursing interventions. This is the correct definition of the evaluation phase of the nursing process, which is the final step where the nurse compares the actual outcomes with the expected outcomes and modifies the plan of care if needed.

Choice B reason:

It involves establishing priorities and measurable outcomes. This is not the correct definition of the evaluation phase, but rather the planning phase of the nursing process, which is the third step where the nurse identifies client goals and interventions based on the nursing diagnosis.

Choice C reason:

It involves identifying gaps between actual and expected findings. This is not the correct definition of the evaluation phase, but rather a component of it. Identifying gaps between actual and expected findings is one way to determine the effectiveness of nursing interventions, but it is not the only way. The evaluation phase also involves documenting and communicating the results of the evaluation.

Choice D reason:

It involves selecting appropriate evidence-based interventions. This is not the correct definition of the evaluation phase, but rather another component of the planning phase of the nursing process, which is the third step where the nurse identifies client goals and interventions based on the nursing diagnosis.

A. "Do you have a family history of heart disease or stroke?.”. B. "How long have you been feeling this way?.”. C. "Are you taking any medications or supplements?.”. D. "What were you doing when the pain started?.".

Correct Answer is B

Explanation

Choice A reason:

Asking about family history of heart disease or stroke is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the client's risk factors, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

Choice B reason:

Asking how long the client has been feeling this way is a priority question for a client who is experiencing chest pain and shortness of breath. This question helps to determine the onset and duration of the symptoms, which are important factors for diagnosing and treating the client. For example, if the client has been feeling this way for more than 20 minutes, it may indicate a myocardial infarction (heart attack), which requires urgent intervention. Therefore, this is the best choice.

Choice C reason:

Asking about medications or supplements is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the client's medical history and possible drug interactions, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

Choice D reason:

Asking what the client was doing when the pain started is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the possible triggers or precipitating factors of the symptoms, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

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A nurse is preparing a diagnostic statement for a client who has chronic obstructive pulmonary disease (COPD) and reports shortness of breath and fatigue with minimal exertion. Which of the following formats should the nurse use to write the statement?

Nursing Test Bank

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A nurse is reviewing the steps of the nursing process with a group of nursing students. Which of the following statements by one of the students indicates an understanding of the evaluation phase?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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