Fundamentals: PREP U Chapter 16

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." Explanation: In the planning stage of the nursing process, the nurse must focus on the client's interests and preferences, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.

Which outcome statements are in the cognitive realm? Select all that apply.

-Within 1 week after teaching, the client will list three benefits of quitting smoking. -By 6/8/20, 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. Explanation: 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 affective quality-of-life outcomes.

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan Explanation: Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. An algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions. A guideline is a statement by which to determine a course of action. An order set is a predetermined set of orders by a prescriber that dictates care of the client.

Which nursing diagnosis is the priority?

Ineffective breathing patterns High-priority nursing diagnoses are those that are potentially life-threatening and require immediate action. Ineffective breathing patterns is the only option that meets this definition.

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in?

Supportive Explanation: Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems. Coordinating interventions involve many different activities, such acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care.

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. Explanation: Outcomes are client-centered, use action verbs, identify measureable performance criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted. Defining characteristics are a component of the nursing diagnosis, not a client outcome. Because outcomes are client-centered, they describe what the client will do, not what the nurse will do.

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. Explanation: The cause of the client health problem is referred to as the etiology. The problem statement of the nursing diagnosis suggests the client goals, and the cause of the problem (etiology) suggests the nursing interventions. Identifying the unhealthy response preventing desired change would occur during the evaluation phase of the nursing process. Client strengths are identified during the nursing diagnosis phase.

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. Explanation: Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The physician does not approve and sign the interventions, because they are nursing interventions.

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

Developing the plan without client input Explanation: Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. There is no indication that the nurse included strategies in the plan of care that did not solve the client's problem. There is no evidence that the care plan needed to be updated or that the nurse failed to do so. Although family support can be important to achieving client outcomes, not every client outcome requires family support.

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

Educational Explanation: Demonstrating, teaching, and observing a return demonstration are classified as educational interventions. The remaining terms refer to aspects of monitoring the client and do not apply to this scenario.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order. Explanation: A physician-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the physician and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding physicians to implement orders, nurses may request a physician to implement an order or question an existing order by the physician if the nurse believes it is in the client's best interests.

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?

Ongoing planning Explanation: Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning.

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. Explanation: While each option is appropriate, it is crucial to find research to support the plan before establishing priorities. The nurse planning care uses clinical reasoning to set priorities that incorporate standards and agency policies, identify and record expected client outcomes, select evidence-based nursing interventions, and record the plan of care.

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?

Standardized Explanation: Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. Initial, ongoing, and discharge are not types of care plans but of planning, in general. Typically, the nurse develops the client's care plan during initial planning and then updates it as needed during ongoing and discharge planning

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing. Explanation: A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nurse-initiated interventions, such as teaching, do not require a physician's order. A physician's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

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. Explanation: Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement.

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?

Upon her admission to the hospital Explanation: Discharge planning should begin when a client is admitted for treatment. All the other times listed are too late and are not consistent with a client who is able to understand the process of the hospitalization.

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family. Explanation: One of the most important considerations in writing outcomes is to encourage clients and families to be as involved in goal development as their abilities and interests permit. The more involved they are, the greater the probability that the goals will be achieved. Patient-centered care focuses on the client needs and desires and thus would not require input from the physician, the nurse manager, or multidisciplinary team.

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 Explanation: An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the expected client outcome. A broad view of evaluation in health care includes three approaches, directed toward structure, process, and outcome, depending on the focus of evaluation and the criteria or standards being used. Process/implementation evaluation determines whether program activities have been implemented as intended. Cost-effectiveness evaluation compares the relative costs to the outcomes (effects) of two or more courses of action. Structure evaluation assesses the effectiveness of various health care structures.

The primary purpose of developing expected client outcomes is to:

provide individualized care. Explanation: The primary purpose of outcome identification is to provide individualized care, but other purposes include to promote participation, to provide care plans that are realistic and measurable, and to allow for involvement of support people. Although the nurse should document outcomes, their primary purpose is not related to facilitating documentation. Although client outcomes are used in evaluation of the client's response to nursing interventions, this is not their primary purpose. Client outcomes do not focus solely on health promotion but may identify a wide array of client health problems, including actual, possible, risk, problem-focused, and health promotion.