Chapter 13

Which of the following is likely to occur if the goal statement is poorly written? 1. There is no standard against which to compare outcomes. 2. The nursing diagnoses cannot be prioritized. 3. Only dependent nursing interventions can be used. 4. It is difficult to determine which nursing interventions can be delegated.

Answer 1 Rationale: Goal statements provide the standard against which outcomes are measured. Nursing diagnoses are prioritized before goals are written (option 2). Both independent and dependent interventions may be appropriate for any goal (option 3). Clarity of the goal does not influence delegation of the intervention (option 4).

Which of the following principles does the nurse use in selecting interventions for the care plan? 1. Actions should address the etiology of the nursing diagnosis. 2. Always select independent interventions when possible. 3. There is one best intervention for each goal/outcome. 4. Interventions should be "doing," not just "monitoring."

Answer 1 Rationale: Interventions should address the etiology of the nursing diagnosis. Both independent and dependent interventions should be selected if appropriate (option 2) and several interventions may be needed for a single outcome (option 3). Both action and assessment-type interventions can be used (options 4).

The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? 1. Hospital policies 2. Standardized care plans 3. Orthopedic protocols 4. Standards of care

Answer 1 Rationale: Policy and procedure documents provide data about how certain situations are handled. Standardized care plans (option 2) and standards of care (option 4) are written for groups of clients with similar medical or nursing diagnoses. They generally do not address questions such as hospital routines and nonmedical client needs. Note: Even hospital policies are not absolute. Each situation must be analyzed and responded to individually. Orthopedic protocols (option 3) would address elements specifically associated with the surgery, not whether the family slept in the room.

The nurse recognizes which of the following as a benefit of using a standardized care plan? 1. No individualization is needed. 2. The nurse chooses from a list of interventions. 3. They are much shorter than nurse-authored care plans. 4. They have been approved by accrediting agencies.

Answer 2 Rationale: Standardized care plans provide a list of interventions from which the nurse can choose. The plan must still be individualized (option 1). Standardized plans could be longer or shorter than nurse-authored ones (option 3), but have not been approved by any outside accreditor (option 4).

The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client's pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but very dry skin. The client declines oral fluid due to nausea, and reports no bowl movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan? 1. Pain 2. Nausea 3. Constipation 4. Potential for wound infection

Answer 2 Rationale: More detailed assessment data and consultation with the client would be needed to absolutely confirm the priority. Postoperative nausea to the level of inhibiting oral intake has the greatest likelihood of leading to complications and requires nursing intervention now. The client's pain level is not extreme considering the recency of the surgery, and pain intervention can be assumed to be effective (option 1). Although the constipation is probably bordering on abnormal, a nursing intervention would most likely begin with oral treatment, which is not possible due to the nausea. More invasive interventions such as an enema or suppository would not be commonly administered the first day postoperative (option 3). Wound infection can occur, but there is no data to indicate that this requires a change in the current plan (option 4).

The care plan includes a nursing intervention "4/2/11 Measure client's fluid intake and output. F. Jenkins, RN." What element of a proper nursing intervention has been omitted? 1. Action verb 2. Content 3. Time 4. None

Answer 3 Rationale: Although there may be standard policies or routines for measuring intake and output, the nursing intervention should specify if this is to be done "routinely" or at specific intervals (e.g., q4h). The nurse is also aware, however, that critical thinking indicates that the intake and output should be monitored more frequently than ordered if assessment reveals abnormal findings.

The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated outcome/goal? 1. Turn in bed q2h. 2. Report the importance of applying lotion to skin daily. 3. Have intact skin during hospitalization. 4. Use a pressure-reducing mattress.

Answer 3 Rationale: The goal or outcome should state the opposite of the nursing diagnosis stem, and thus healthy intact skin is the reverse condition of impaired skin integrity. Turning in bed, applying lotion, and using a special mattress are all interventions that may result in achieving the goal (options 1, 2, and 4).

Place the following activities of planning in the correct order of their use. 1. Establish goals/outcomes. 2. Write the care plan. 3. Set priorities. 4. Choose interventions.

Answer 3, 1, 4, and 2 Rationale: In planning, first the nurse sets priorities and then writes goals/outcomes, selects interventions, and then writes the nursing care plan.

When written properly, NOC outcomes and indicators 1. Do not require customization. 2. Address several nursing diagnoses. 3. Are broad statements of desired end points. 4. Reflect both the nurse's and the client's values.

Answer 4 Rationale: NOC outcomes should reflect both the nurse's and the client's values of what is trying to be achieved. The outcomes still must be customized (option 1), but address only one nursing diagnosis at a time (option 2). Outcomes are narrow/specific end points, not broad (option 3).

After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be the least useful during the first shift on the orthopedic unit? 1. Initial 2. Ongoing 3. Discharge 4. Strategic

Answer 4 Rationale: Strategic planning is an ongoing process focused on organizational change rather than individual clients so it is least useful and not relevant in this case. The client requires initial planning because he has just arrived on the orthopedic unit for the first time (option 1). Of the three types of planning that need to be done at this time, initial is the highest priority since he has just had surgery. The client also requires the ongoing type of planning necessary to determine the care appropriate for this shift (option 2). Discharge planning needs to start on admission to ensure adequate client preparation for management of health needs outside the health agency (option 3).