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 lack of knowledge as a diagnostic label. The nurse identifies the action taken is an example of what concept of Nursing diagnosis formation?

Question

Quizplus · Accepted Answer

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, missing the true underlying etiology of a problem, using medical diagnoses as related factors in a NANDA-I Nursing diagnostic statement, and identifying multiple Nursing diagnosis labels in one NANDA-I 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. "Lack of knowledge" is not a medical diagnosis.

The Nurse in an Outpatient Clinic Obtains a Blood Pressure