Chapter 13: PREPU

Question 31

The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is: ANSWER: A clinical pathway (A clinical pathway communicates the standardized, interdisciplinary plan of care for a client. Care guidelines and outcomes are specified for each day of the client's hospital stay. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. An order set is a preprinted set of provider orders that expedite the provider order process. A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of clients within the cohort. It has a broader specificity than an algorithm and allows for minimal provider flexibility by way of treatment options.)

Question 15

A client has just given birth to a stillborn infant. The client is sobbing and states she feels God is punishing her for some bad choices in her past. She states she has always believed in God as a loving and caring presence in her life but now feels her faith is destroyed. Which nursing diagnoses would be included in the patient's care plan? Select all that apply ANSWER: >Spiritual Distress >Grieving

Question 1

A nurse is formulating a nursing plan of care for a client based on assessment data. When writing this plan, which would be most important for the nurse to include? ANSWER: Interventions

Question 18

A nursing student is writing a student care plan for an assigned client. When identifying specific interventions to be used, which aspect would the student need to include with the interventions? ANSWER: Scientific rationales

Question 26

A nurse is working with a newly admitted client with diabetes to develop client outcomes. When writing these outcomes, which verb would be appropriate to use in the statement. Select all that apply. ANSWER: >Demonstrate >State >Explain (When writing client outcomes it is important that an action verb is used so that the behavior can be evaluated.)

Question 12

When creating a care plan, which is the purpose of identifying the client outcome? ANSWER: To design a plan of care to address the health problem (The primary purpose of the outcome identification and planning step of the nursing process is to design a plan of care with and for the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes.)

Question 10

The nurse is developing a plan of care for a client. When planning care in the outcome identification phase, what does the nurse determine is the benefit of this phase? ANSWER: It promotes the client being an active participant in care (Outcome identification serves the purpose of promoting client participation. Evaluation takes place after interventions have been performed.)

Question 11

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2015." Why is this outcome inadequate? ANSWER: Outcome is not observable or measurable. (The verb in this outcome "know" is not directly measurable or observable. The verb "demonstrate" would be more appropriate.)

Question 13

A committee of nurses on a hospital unit is developing a clinical pathway for a high-risk group of clients. This pathway will include steps for assessment and interventions in which there will be no flexibility for the nursing staff. What is this structured care methodology called? ANSWER: Algorithm (Algorithm is useful in the management of high-risk groups. It includes steps in the assessment and interventions the nurses will use. There is no provider flexibility. A concept map is a flexible tool used to plan care.)

Question 28

A nurse is performing initial care planning for a hospitalized client. Which actions occur during the initial planning of client care? Select all that apply. ANSWER: >The nurse who performs the admission nursing history and physical assessment makes the initial plan. >After the initial plan is developed, the nurse prioritizes nursing diagnoses. >The nurse identifies client goals and the related nursing care in the initial plan.

Question 27

A nurse is using the Nursing Outcome Classification system to assist in planning a client's care. The nurse understands that each outcome includes which component? Select all that apply. ANSWER: >Definition >Measurement scale >Indicators >Target time

Question 5

The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care? ANSWER: 45-year-old man with burns to his upper arms and chest and soot on his face who is restless and anxious (Burns to the chest and soot on the client's face indicate that the client inhaled hot smoke and is at risk for ineffective airway clearance due to possible tracheal/bronchial edema. Restlessness and anxiety can indicate hypoxia and are characteristics of the nursing diagnoses of impaired gas exchange and acute confusion.)

Question 29

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client and family's ability to cope. What action should the nurse take with this client? ANSWER: Comfort the family

Question 6

The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply. ANSWER: >After attending an infant care class, the client will correctly demonstrate the procedure for bathing her newborn. >By 4/5/15, the client will demonstrate how to care for a colostomy. >After counseling, the client will describe two coping measures to deal with stress. (Goals must be client-centered, specific, measurable, attainable, realistic, and timebound.)

Question 17

The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply. ANSWER: >After attending an infant care class, the client will correctly demonstrate the procedure for bathing her newborn. >By 4/5/15, the client will demonstrate how to care for a colostomy. >After counseling, the client will describe two coping measures to deal with stress. (demonstrating a technique is measurable, but "will know" is not measurable.)

Question 2

A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse? ANSWER: Perform hourly neurovascular assessment. (The nurse modifies the plan of care to increase the frequency of assessment in order to identify further complication. While the other nursing interventions are routine comfort measures used following injury, they are not sufficient to treat the complication.)

Question 20

A nurse is planning care for clients in a physician's office. Which actions will the nurse perform during this step of the nursing process? Select all that apply. ANSWER: >Establishing priorities >Identifying expected client outcomes >Selecting evidence-based nursing interventions >Communicating the plan of nursing care (During the planning phase of the nursing process the nurse establishes priorities, identifies and writes expected client outcomes, selects evidence-based nursing interventions, and communicates the plan of nursing care. Recording client outcomes occurs during evaluation stage)

Question 4

A nurse is reviewing the outcome criteria that were developed for a client. The nurse determines that the criteria are appropriate because which characteristic is met? Select all that apply. ANSWER: >Can be measured >Are realistic >Are specific (Outcome criteria are specific, measurable, realistic statements of goal attainment. They may restate the goal, but they also present information that will guide the evaluation phase of the nursing process.)

Question 23

A nurse is reviewing the plan of care for a client and notes : "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." How does the nurse interpret this ANSWER: Outcome criteria (This statement is an example of outcome criteria. Outcome criteria answer the questions who (the client), what actions (verbalizes), under what circumstances (to the staff), how well (accurately), and when (before discharge).

Question 25

A nurse is using the SMART acronym to plan outcomes for clients in a long-term care facility. Which criteria describe the use of this acronym? Select all that apply. ANSWER: >S = goals should be specific >M = goals should be measurable >R = goals should be realistic >T = goals should be temporary (S - specific; M - measurable; A - attainable; R - realistic; T - timebound)

Question 32

A nurse reviews the client outcomes written by a student nurse. Which outcome requires modification? ANSWER: By the end of instruction, client will know how to perform dressing changes

Question 9

A nurse writes down the following outcome for a depressed client: "By 6/9/12, the client will state three positive benefits of receiving counseling." This is an example of which type of outcome? ANSWER: Affective (Affective outcomes describe changes in client values, beliefs, and attitudes. Psychomotor outcomes describe the client's achievement of new skills. Cognitive outcomes describe increases in client knowledge or intellectual behaviors.)

Question 8

A nursing student is writing a care plan for an assigned client to be submitted to the instructor. Before submitting the care plan the student reviews it to ensure that all the necessary components have been addressed. Which component would the student look for? Select all that apply. ANSWER: >Nursing diagnoses >Client goals >Outcome criteria >Interventions with rationales >Evaluation

Question 24

The nurse assigned to care for a client has established client outcomes and outcome criteria. After completing this task, what would the nurse do next? ANSWER: Write a client plan of care

Question 16

The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. Which outcome statement is structured correctly? ANSWER: By discharge from the fertility clinic, the client will achieve full-term pregnancy.

Question 21

The nurse is developing cognitive outcomes for a client. Which outcome statements would be in the cognitive realm? Select all that apply. ANSWER: >Within 1 week after teaching, the client will list three benefits of quitting smoking. >By 6/8/15, the client will describe a meal plan that is high in fiber. >After viewing the film, the client will verbalize four benefits of daily exercise. (Cognitive outcomes describe increases in client knowledge or intellectual behaviors. Listing benefits of quitting smoking, describing meal plans, and verbalizing benefits of exercise demonstrate increased client knowledge. Administering an injection demonstrates a psychomotor outcome. Verbalizing the valuing of a healthy diet and benefits of daily exercise demonstrate quality- of-life outcomes.)

Question 14

The nurse is planning the care of a client. What behaviors reflect planning?Select all that apply. ANSWER: >The nurse decides to assist the client with ambulation in the hallway twice per shift. >The nurse seeks input from the client and family regarding acceptable non-pharmacologic pain management strategies. >The nurse considers the developmental level of the client when selecting education materials.

Question 30

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: ANSWER: A guideline (A guideline is defined as a broad, research-based practice recommendation that may or may not have been tested in clinical practice. An algorithm has intense specificity and provides no provider flexibility; it is used to manage high-risk groups within a cohort. A critical pathway represents a minimal practice standard for a specific client population. An order set includes preprinted provider orders used to expedite the order process.)

Question 3

A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking, again." What is the priority nursing diagnosis? ANSWER: Deficient Diversional Activity

Question 22

The nurse is writing a measurable outcome for a client with a new prosthesis to begin walking again. Which components must be included in the outcome? Select all that apply. ANSWER: >The action the client will perform >Particular circumstances in which the outcome is to be achieved >The client or some part of the client >Target time when the client is expected to be able to achieve the outcome

Question 7

The nurse is writing care plans for clients in the team. Which is an appropriate expected outcome for a client? ANSWER: Client will independently follow transplant medication schedule 1 week after surgery. (Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable, such as "know" and "understand.")

Question 19

The nurse understands that which of the following are part of client-centered outcomes? Select all that apply. ANSWER: >The outcome demonstrates resolution of the nursing problem. >Long-term outcomes may be used as discharge goals. >Expected client outcomes are used to evaluate achievement. >Goals and outcomes are interchangeable.