chapter 16 prep u

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

"Please tell me your thoughts about treating this diagnosis."

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm.

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

Educational

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

On the client's admission to the hospital

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

Outcome

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor

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?

Scientific rationales

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing.

Which outcome for a client with a new colostomy is written correctly?

The client will demonstrate proper care of the stoma by 3/29/20.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent?

Verb (action)

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective?

Client will use chin tuck and double swallow for each bite.

Which components must be included in an outcome? Select all that apply.

The action the client will perform The particular circumstances in which the outcome is to be achieved The client or some part of the client A target time by which the client is expected to be able to achieve the outcome

A nurse writes down the following outcome for a depressed client: "By 6/9/20, the client will state three positive benefits of receiving counseling." This is an example of which type of outcome?

Affective

A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client?

Passive abduction with assistance

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

identifies factors causing undesirable response and preventing desired change.

A nurse is caring for a client admitted for bowel obstruction, which now has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply.

orrect response: Auscultate for bowel sounds. Begin feedings with clear broth. Consult with a dietitian regarding appropriate foods.

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

outcome

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?

Start from client's knowledge, teach about diet modifications, and check for learning.