Module 4 (Nursing Process)

B.) Critical pathway "A standardized plan of care is developed to address goals and expected outcomes for nursing interventions." "There are specific types of nursing plans of care. These can be directed at discharge needs, expected goals, and outcomes, and can be unique to a particular diagnosis or procedure."

A nurse performs an admission assessment on a client who is admitted with pneumonia. The nurse then creates an outcome-based, interdisciplinary plan that sequences care and expectations for clients with pneumonia. What do these actions describe? A.) Discharge plan B.) Critical pathway C.) Standardized care plan D.) Problem list

B.) Objective "Objective data is measurable or observable data. An elevated temperature is obtained by measurement." "This data can be observed or measured through visualization, palpation, auscultation, or percussion; it is not associated with a client complaint or reported symptoms."

During an assessment, the nurse notes that the client has an elevated temperature. Which type of data is this? A.) Subjective B.) Objective C.) Secondary D.) Reported

A.) Assessment "The assessment of psychosocial needs is important information for the development of the care plan, which must reflect the social aspects of Mary's care."

Mary is a 17-year-old, diagnosed with a brain tumor, who has recently begun chemotherapy. The nurse asks her how being hospitalized is impacting her senior year of high school. Which nursing process does this represent? A.) Assessment B.) Diagnosis C.) Planning Outcomes D.) Planning Interventions E.) Implementation F.) Evaluation

E.) Implementation "This is an example of delegation, part of the implementation phase of the nursing process."

Mrs. Clancy is a nursing home patient at risk for falls. The head nurse asks one of the unlicensed assistive personnel to assist Mrs. Clancy to the dining hall and help prepare her for dinner. Which nursing process does this represent? A.) Assessment B.) Diagnosis C.) Planning Outcomes D.) Planning Interventions E.) Implementation F.) Evaluation

D.) Analyzing data

The diagnosis step of the nursing process includes which activity? A.) Assessing and diagnosing B.) Evaluating goal achievement C.) Performing and documenting nursing actions D.) Analyzing data

A.) The client has most likely not had a recent physical examination [Pg. 41] "Assessing the client for health and illness involves many components, including the client's lifestyle."

The nurse in a community clinic is assessing a 23-year-old client who reports upper respiratory congestion and a cough that has lingered for 3 weeks. In the initial interview, the nurse learns the client's family lives out of state and that the client goes to school part-time while waiting tables part-time. What might the nurse infer from this information? A.) The client has most likely not had a recent physical examination. B.) The client's parents have provided healthcare up to this point. C.) Waiting tables places the client at a higher risk for developing illnesses. D.) The client's age indicates he or she may not be compliant.

A.) Stating that the client will report feeling less distress at social gatherings B.) Selecting the best antidepressant for the client C.) Recommending a cognitive behavioral therapist for the client [Pg. 41] "When assessing a client and planning outcomes, multiple factors play a role in the success of the client's outcomes and his or her willingness to be compliant."

The nurse is assigned to a client who experiences major depression and anxiety. Which steps are part of the planning stage of the nursing process? Select All That Apply. A.) Stating that the client will report feeling less distress at social gatherings B.) Selecting the best antidepressant for the client C.) Recommending a cognitive behavioral therapist for the client D.) Taking the client's vital signs with special attention paid to blood pressure

A.) The nursing process is a critical-thinking, problem-solving model.

Which statement is correct about critical thinking and the nursing process? A.) The nursing process is a critical-thinking, problem-solving model. B.) When using the nursing process, critical thinking is not needed. C.) Everything a nurse does requires critical thinking. D.) Nursing process is the only form of critical thinking used in nursing.

C.) Interdependent

A nurse notes that a client newly diagnosed with chronic obstructive pulmonary disease and emphysema has been seen by the respiratory therapist, who taught and provided materials on oxygen use. The nurse observes the client is not using the cannula as directed and notes that the client is removing it when visitors are present. The nurse explains how important using the oxygen is, reviews proper cannula placement, and communicates the assessments and teaching to the respiratory therapist. Which type of intervention has this nurse implemented? A.) Independent B.) Dependent C.) Interdependent D.) Autonomous

C.) Adequate hydration A.) Falls prevention B.) Support group E.) Medication teaching D.) A vase of flowers [Pg. 48] "Physiological needs, such as adequate hydration, are the highest priority when considering meeting a client's needs. Falls prevention is a safety and security need, which is the second level of Maslow's Hierarchy. Love and belonging is the third level of Maslow's Hierarchy. A support group meets the client's need to feel part of something. Medication teaching is a cognitive need, which is the fifth level of Maslow's Hierarchy. Beautiful flowers to look at fulfills the aesthetic Need or the need for beauty and order, which is the sixth level of needs in Maslow's model."

According to Maslow's Hierarchy of Needs, what is the appropriate order of priority of the client needs A.) Falls prevention B.) Support group C.) Adequate hydration D.) A vase of flowers E.) Medication teaching

A.) Physical care B.) Emotional support C.) Client education

Which nursing interventions are considered direct-care interventions? Select All That Apply. A.) Physical care B.) Emotional support C.) Client education D.) Making a referral E.) Managing the environment

A.) Administer laxative or stool softener as prescribed. B.) Encourage increased fluid intake, including warm liquids. C.) Educate the client about and encourage a high-fiber diet [Pg. 93 -Meet Your Patient-]

A postsurgical client has a new nursing diagnosis of "Constipation related to immobility and decreased gastrointestinal (GI) motility secondary to narcotic analgesics." Which are appropriate nursing interventions for this client? Select All That Apply. A.) Administer laxative or stool softener as prescribed. B.) Encourage increased fluid intake, including warm liquids. C.) Educate the client about and encourage a high-fiber diet. D.) Discontinue analgesic. E.) Encourage an increased exercise program.

C.) Create a working problem list. D.) Identify problems that can be managed with a critical pathway or standardized plan of care. A.) Individualize the standardized plan as needed. B.) Transcribe medical orders to the appropriate documents. F.) Address ADLs and basic care needs as part of the plan of care. E.) Develop care plans for problems not addressed by the standardized documents. [Pg. 78 - 79] "Creating an individualized nursing care plan should begin with creating a working problem list. If there is a diagnosis on the problem list that has an associated critical pathway, that should be implemented. Identify individual goals and specific client needs as part of the plan of care. Incorporating medical orders is part of the collaboration of a nursing care plan. Basic daily care needs should be addressed as part of the individualized care plan. If a client has unique needs or problems that are not applicable to the plan of care, those should be included, possibly as an addendum to the plan of care." "Approach an individualized care plan in a systematic method, using the same techniques each time. The problem list will guide the goals and expected outcomes."

Correctly order the steps in creating a nursing care plan. A.) Individualize the standardized plan as needed. B.) Transcribe medical orders to the appropriate documents. C.) Create a working problem list. D.) Identify problems that can be managed with a critical pathway or standardized plan of care. E.) Develop care plans for problems not addressed by the standardized documents. F.) Address ADLs and basic care needs as part of the plan of care.

A.) Assessment "The nurse knows that a diet high in sodium can impact hypertension. By inquiring about dietary intake, the nurse can identify areas of education that must be included in the plan of care."

Mr. Patel was recently started on a new hypertension medication. During a home visit, the nurse asks what Mr. Patel has eaten in the last 24 hours. Which nursing process does this represent? A.) Assessment B.) Diagnosis C.) Planning Outcomes D.) Planning Interventions E.) Implementation F.) Evaluation

E.) Implementation "The implementation phase of the nursing process is the "action" phase. The injection given by the nurse is the action performed to control Mr. Thompson's pain and allow him more comfort with activity."

Mr. Thompson had surgery yesterday for a hernia repair. His pain is significant. The nurse delivers an injection of pain medicine 30 minutes before Mr. Thompson needs to ambulate in the hall. Which nursing process does this represent? A.) Assessment B.) Diagnosis C.) Planning Outcomes D.) Planning Interventions E.) Implementation F.) Evaluation

C.) Planning Outcomes "This statement documented in the client's record is a long-term goal, a part of planning outcomes. Care plan goals are both short-term and long-term. A short-term goal would be "no falls will occur in the next 24 hours" or "client will ask for assistance each time she gets out of bed."

Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was "no further falls will occur while in the care center." Which nursing process does this represent? A.) Assessment B.) Diagnosis C.) Planning Outcomes D.) Planning Interventions E.) Implementation F.) Evaluation

F.) Evaluation "With the evaluation of the plan of care, constant reappraisal is required and alterations are made in the original plan to ensure its currency and relevance."

The nurse is caring for Ms. Lee, a client who does not speak English. The nurse learns from the patient's family that Ms. Lee has specific religious needs that she cannot address because of the hospital routine. Adjustments are made in the plan of care based on this information Which nursing process does this represent? A.) Assessment B.) Diagnosis C.) Planning Outcomes D.) Planning Interventions E.) Implementation F.) Evaluation

D.) Religious and spiritual needs

The nurse is performing an assessment on a client. What should be included in this process? A.) Ability to pay for hospital stay B.) Who brought patient to the hospital C.) Level of education D.) Religious and spiritual needs

C.) Planning Outcomes "Discharge planning should begin at admission. This process can often take days to coordinate and may prolong the client's hospital stay if not started right away. This identification of discharge needs is a part of planning patient outcomes."

The nurse, Linda, identifies some concerns about her patient's financial situation and ability to pay the hospital bill. She approaches the healthcare provider to request that a social worker meet with the client prior to discharge. Which nursing process does this represent? A.) Assessment B.) Diagnosis C.) Planning Outcomes D.) Planning Interventions E.) Implementation F.) Evaluation

F.) Evaluation "When goals of the nursing care plan are met, the plan of care should be updated to reflect that."

Upon discharge, the nurse realizes that all care plan goals were met. The documentation is updated to reflect this.Which nursing process does this represent? A.) Assessment B.) Diagnosis C.) Planning Outcomes D.) Planning Interventions E.) Implementation F.) Evaluation

A.) Ineffective airway clearance D.) Ineffective breathing pattern C.) Deficient fluid volume B.) Risk for fall F.) Wandering E.) Impaired memory [Pg. 63] "Physiological needs make up the base of Maslow's hierarchy; these needs must be met before any other needs can be met. Therefore, ineffective airway clearance, which affects a client's ability to breathe and may present a life-threatening situation, is the top priority. An ineffective breathing pattern is the second priority. Deficient fluid volume is also a physiological need and is the third priority. A risk for falls is higher in the hierarchy under safety, followed by wandering, which may affect a person's security. Impaired memory is in the third tier of the hierarchy, love and belonging, making it the lowest priority."

Using Maslow's hierarchy of needs, place the nursing diagnoses in order of priority. A.) Ineffective airway clearance B.) Risk for fall C.) Deficient fluid volume D.) Ineffective breathing pattern E.) Impaired memory F.) Wandering Your Response - 1,4,3,2,6,5

A.) Assessments must be completed within 24 hours of inpatient admission. B.) Assessment cannot be delegated to others. C.) All clients are assessed for pain, nutritional status, and risk for falls. [Pg. 41-42]

What does the nurse know is true about conducting the nursing assessment? Select All That Apply. . A.) Assessments must be completed within 24 hours of inpatient admission. B.) Assessment cannot be delegated to others. C.) All clients are assessed for pain, nutritional status, and risk for falls. D.) Vital signs can always be conducted by nursing assistive personnel. E.) Assessments are not required for clients who are not being admitted. F.) Administering a sedative to the client

A.) Giving a medication C.) Obtaining vital signs D.) Giving a bedside bath [Pg. 94] "Direct nursing care describes care that is given during an actual encounter with the client."

Which are examples of a direct-care nursing intervention? Select all that apply. A.) Giving a medication B.) Notifying the physician of a change in assessment C.) Obtaining vital signs D.) Giving a bedside bath E.) Consulting case management for home oxygen

A.) Hard, painful bowel movement approximately every 3 to 4 days; sedentary lifestyle; low dietary fiber intake; dry skin B.) Pain and limited range of motion in knees, use of walker, medical diagnosis of osteoarthritis E.) Urinary incontinence, lower abdominal pain, bladder spasm [Pg. 61] "Clusters of cues establish a pattern when they are related, making nursing diagnosis more efficient and accurate."

Which are examples of cue clusters for a nursing diagnosis? Select All That Apply. A.) Hard, painful bowel movement approximately every 3 to 4 days; sedentary lifestyle; low dietary fiber intake; dry skin B.) Pain and limited range of motion in knees, use of walker, medical diagnosis of osteoarthritis C.) Sore throat, fever, inability to ambulate, medical diagnosis of depression D.) Dry skin, painful urination, epistaxis E.) Urinary incontinence, lower abdominal pain, bladder spasm

A.) Risk for impaired skin/tissue integrity B.) Ineffective impulse control C.) Insufficient breast milk [Pg. 58] "Nursing diagnoses involves the health status of a client and how the nurse can best assist the client in improving."

Which are examples of nursing diagnoses? Select All That Apply. A.) Risk for impaired skin/tissue integrity B.) Ineffective impulse control C.) Insufficient breast milk D.) Renal failure E.) Emphysema with chronic obstructive pulmonary disease (COPD)

A.) Graphic flow sheet B.) Intake and output sheet [Pg. 50] "Tools used for recording assessment data can be utilized to track assessment findings over a period of time. Data points that can be graphed can identify any changes in client assessment."

Which are tools for recording assessment data? Select all that apply. A.) Graphic flow sheet B.) Intake and output sheet C.) Client handbook D.) Shift report form E.) Primary survey

A.) Doing C.) Delegating D.) Documenting [Pg. 108] "During implementation, taking action on planned interventions involves doing, delegating, and documenting. All actions must be done, assigned to others, and documented. Of course, all actions are then evaluated as the next part of the nursing process."

Which describes components of implementation in the nursing process? Select all that apply.. A.) Doing B.) Deciding C.) Delegating D.) Documenting E.) Caring

A.) Client will verbalize reduced pain with pain management interventions to a satisfactory level within a 12-hour period [Pg. 84] " A goal statement begins with a subject (client) and include an action verb (verbalize), performance criteria (reduced pain), and a target time (12-hour period)."

Which is an appropriate goal statement for a postpartum female client with a nursing diagnosis of "lower abdominal pain r/t uterine contractions and hyperextension of cervix"? A.) Client will verbalize reduced pain with pain management interventions to a satisfactory level within a 12-hour period B.) Uterus will cease contracting after treatment within 2 hours C.) Lower abdominal pain will be relieved by analgesics as prescribed by physician D.) Client will ambulate to the bathroom at least twice within 8 hours to relieve pressure from abdomen

A.) A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is geared toward the client's health status and how a nurse can help independently. [Pg. 58] "A medical diagnosis describes a disease, illness, or injury, and the purpose is to find pathology. A nursing diagnosis is a statement of client health status that nurses can identify, prevent, or treat independently."

Which is the best explanation of the difference between a medical diagnosis and a nursing diagnosis? A.) A medical diagnosis defines an illness or disease with a certain pathology, while a nursing diagnosis is geared toward the client's health status and how a nurse can help independently. B.) A medical diagnosis is made by a physician, and a nursing diagnosis is created by a nurse. C.) A medical diagnosis involves interventions and medical treatment, and a nursing diagnosis involves client comfort and activities of daily living. D.) A medical diagnosis determines the nursing diagnosis, while the nursing diagnosis has no bearing on the medical diagnosis.

D.) Functional needs assessment "A functional needs assessment is an assessment of a person's ability to live independently. Aging often brings about a change in baseline functional status, which should be evaluated periodically."

Which is the definition of an assessment of a client's ability to perform self-care and live independently?. A.) Wellness assessment B.) Cultural assessment C.) Family assessment D.) Functional needs assessment

A.) Works alongside an individualized plan of care

Which of the following about the nursing process is correct? A.) Works alongside an individualized plan of care B.) Results in outcomes designed by the client C.) Composed of a linear process with unique, distinct steps D.) Includes only the care that the nurse will deliver

A.) "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal."

Which statement or command made by the nurse is an example of the evaluation phase of the nursing process? A.) "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal." B.) "Mr. Sullivan will be able to walk the length of the hallway before discharge." C.) "Mr. Sullivan may be able to ambulate with the use of a walker and stand-by assistance." D.) "Ambulate Mr. Sullivan in the hallway three times today, please."

B.) Focused assessment [Pg. 45] "Nursing assessments can be made upon initial client contact or at intervals. Assessments can be complete health or body assessments, or they can focus on a particular problem or specific data set."

Which type of assessment is performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected? A.) Initial assessment B.) Focused assessment C.) Global assessment D.) Special needs assessment

A.) Functional and self-care limitations B.) Emotional stability and ability to learn C.) Family or other caregivers available D.) Use of community services before admission [Pg. 77]

Which type of data should be included in the discharge planning? Select All That Apply. A.) Functional and self-care limitations B.) Emotional stability and ability to learn C.) Family or other caregivers available D.) Use of community services before admission E.) Medical diagnosis

A.) Ongoing evaluation "Ongoing evaluation is performed frequently, as part of client assessment, and while implementing care."

Which type of evaluation is performed while implementing care, immediately after an intervention, and at each client contact? A.) Ongoing evaluation B.) Intermittent evaluation C.) Terminal evaluation D.) Subjective evaluation

B.) Diagnosis "Diagnosis includes the analysis of the data collected. This is the thinking phase needed to link the problems to the plan of action."

Adrian, a nurse, reflects on her client's admission information, including physical assessment and related family concerns. She considers all information to reach conclusions. Which nursing process does this represent? A.) Assessment B.) Diagnosis C.) Planning Outcomes D.) Planning Interventions E.) Implementation F.) Evaluation

C.) The safety and physical layout of the home environment

A client is admitted for a hip fracture following a fall at home. The client has surgery to repair the fracture and is getting ready for discharge. The client is using a walker to ambulate and working with physical therapy. Which is an important consideration for this client for discharge planning? A.) Ability to pay for continued physical therapy B.) Community resources available C.) The safety and physical layout of the home environment D.) Compliance with follow-up appointments

D.) Planning Interventions "Intervention planning must include current best practices. Evidence-based policy will validate that the client is receiving research-based interventions in his or her plan of care."

Rosalind, a nurse, considers the most recent evidence-based policy on care of the client with pneumonia while identifying patient needs. Which nursing process does this represent? A.) Assessment B.) Diagnosis C.) Planning Outcomes D.) Planning Interventions E.) Implementation F.) Evaluation

A.) Basic three-part statement [Pg. 68] "The abbreviation "PES" (problem, etiology, symptom) is used when writing a basic three-part statement, which uses "AEB" (as evidenced by) and "AMB" (as manifested by) as connecting phrases."

The abbreviations "AEB" and "AMB" are considered connecting phrases for which portion of the nursing plan? A.) Basic three-part statement B.) Two-part NANDA-I label C.) Collaborative problem D.) Complex etiology

A.) The subjective information may be skewed due to confusion and disorientation. [Pg. 42 - 43] "During the collection of data from a client, there are various reasons to question the validity of information being provided"

A client is admitted to the emergency department with pain in the chest radiating to the back, numbness in the jaw, and confusion and disorientation. When asked how long the symptoms have persisted, the client reports about a week. What should the nurse consider? A.) The subjective information may be skewed due to confusion and disorientation. B.) The objective information is all the nurse needs to create a nursing plan. C.) The chest pain is indicative of an infarction that needs immediate intervention. D.) The nurse should immediately call a family member to verify the duration of the pain.

B.) Ongoing planning "Ongoing planning is continuous throughout the duration of care and updated as the status changes."

A client was admitted 2 days ago has not slept well due to pain from injuries. The nurse recognizes this while making rounds and adjusts the client's nursing diagnosis to reflect the change in status. The nurse then creates a new plan to address the change. What type of planning is this considered? A.) Initial planning B.) Ongoing planning C.) Discharge planning D.) Preexisting planning

C.) Request assistance with ambulating the client. [Pg. 110] "If an implementation is difficult, or the nurse is not comfortable performing the action alone, then appropriate resources should be obtained to assist with meeting the client's needs."

A nurse has created a plan of care that involves assisting a client with ambulation. She attempts to get the client out of bed, but the client is obese and unable to move without pain. What action should the nurse take? A.) Change the outcome goals. B.) Document the attempt to ambulate the client. C.) Request assistance with ambulating the client. D.) Amend the nursing diagnosis and interventions.