NUR FUND Chapter #13 + Prep u

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."

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."

Rules for outcomes

-never use increase or decrease unless you explain in detail what you are looking for. must be positive and measurable

The nurse recognizes that health problems that can be prevented by independent nursing interventions are called what?

Actual or potential nursing diagnoses

Syndrome nursing diagnoses

Address a cluster of actual or risk diagnoses that are predicted to be present as a result of a certain event or situation. (less)

Formula of the diagnosis statement

Begins with problem, followed by the probable cause called etiology( or contributing factors). The etiology follows the related to.

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.

Can be measured Are realistic Are specific

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 normal tensive.

The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply.

Client will increase nutrition, eating 75% of meals. Client will report pain is controlled at or below 3 of 10. Client will perform dressing change independently.

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.

A nurse is planning nursing interventions for patients on a busy hospital unit. Which guideline would the nurse follow when designing the plan of care?

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

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged 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

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

Discharge planning

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

Educational Care

A nurse administers colchicine according to the standardized plan of care for a client admitted with acute gouty arthritis of the right great toe. Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention?

Foot remains red and swollen.

The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?

Mr. Conner will demonstrate proper care of stoma by 29MAR2015.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

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.

A nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The nurse then uses the data to update the client plan of care. What are these actions considered?

Ongoing Care Planning

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority?

Resolve the client's anxiety.

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

Supportive Intervention

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:

The patients condition.

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 her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?

Upon her admission to the hospital

What are the defining characteristics?

data showing why you picked that diagnosis, broken up by subjective data

Outcome criteria

described specific, measurable, observable responses from the pt (expected conclusion to problem) -they determine that the goal has been achieved -it is the reverse of the defining characteristics and the assessment data -positively stated what the nurse wants to happen -should be VERY specific so someone else can take the pts data and determine whether or not the pts goal was met - they come from the defining characteristics

What are expected outcomes?

desired resolution of the health problem. (aim or end). Always make the statement positive (opposite of the problem). Must give a date and time frame!

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually:

does not contain documented scientific rationales.

Interventions address the etiology of the diagnostic statement and meeting the pts overall

expected outcomes or goals

When do you plan?

initially (on admission), ongoing(as the plan is carried out), discharge(begun on admission and completed when the pt is discharged.

nurse interventions are:

nurse initiated, MD, or health collaborative . always individualized!!

Collaborative diagnoses

selected when the nurse needs to work with another member of the health care team in order to assist the client in resolving the health issue.

The problem statement of the nursing diagnosis suggests what 2 things?

the patient goals, and the cause of the problem (etiology) suggests the nursing interventions

A nurse is using the SMART acronym to plan outcomes for patients in a long-term care facility. Which criteria describe the use of this acronym? (Select all that apply.)

• S = goals should be specific • M = goals should be measurable • R = goals should be realistic • T = goals should be temporary

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 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.

A nurse is caring for a 48-year-old man 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 evaluation

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

Psychomotor

The nurse understands that which of the following are part of client-centered outcomes? Select all that apply.

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.

Evaluation is based on what?

the pts outcome (goals) and the outcome criteria, NOT the interventions

Which intervention performed by the nurse is most appropriate for assisting a client in meeting physiologic needs based on Maslow's Hierarchy of Needs?

Cutting up food and opening drink containers for the client

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.

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention?

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

A 63-year-old client in the ICU with a nursing diagnosis of risk for impaired skin integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to her left side she notices that the client has a non-blanching reddened area over her right trochanter. What would be the most appropriate action for the nurse to take?

The nurse repositions the client to her left side and updates the plan of care to turn and reposition the client every hour.

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.

A nurse identifies outcomes of care for the hospitalized, postoperative client primarily to:

provide individualized care.

Dependent nursing diagnoses

require a specific written order from the primary health care provider in order to be executed by the nurse.

Why do we plan?

to identify the nurses goal and appropriate nursing interventions to prevent, reduce, or eliminate a pts health problem.