Nurs 222 Chapter 16 CoursePoint

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? a) Supportive b) Psychosocial c) Coordinating d) Supervisory

a) Supportive

The nurse recognizes that identifying outcomes/goals must include: a) involvement of the client and family. b) input from the physician. c) input from the multidisciplinary team. d) involvement of the nurse manager and other staff nurses.

a) involvement of the client and family.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? a) Maintenance b) Surveillance c) Psychomotor d) Psychosocial

c) Psychomotor

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: a) diagnosis b) evaluation c) intervention d) goal

c) intervention

What are specific measurable and realistic statements of goal attainment? a) Nursing diagnoses b) Nursing interventions c) Evaluations d) Outcomes

d) Outcomes

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? a) Client will have formed stools within 24 hours. b) Client will eat small meals of bland foods for 3 days. c) Client will identify the food that caused the condition within 3 hours. d) Client will maintain adequate hydration within 2 days.

a) Client will have formed stools within 24 hours.

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? a) Encourage hourly use of the incentive spirometer. b) Promote oral fluid intake between meals. c) Provide oral pain medication before ambulation. d) Reassess in 4 hours and document the findings.

a) Encourage hourly use of the incentive spirometer.

Which are characteristics of appropriate client outcome statements? Select all that apply. a) Measurable b) Realistic c) Short-term d) Specific e) Broad in scope

a) Measurable b) Realistic d) Specific

Which statement correctly describes a nurse-initiated intervention? a) Nurse-initiated interventions are derived from the nursing diagnosis. b) Nurse-initiated interventions require a physician's order. c) Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. d) Nurse-initiated interventions are actions performed to diagnose a medical problem.

a) 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? a) On the client's admission to the hospital b) Once the client has received a discharge order c) As soon as possible after the client's surgery d) Once the client is admitted to the nursing unit from postanesthetic recovery

a) On the client's admission to the hospital

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? a) Scientific rationales b) Outcome criteria c) Goals d) Nursing orders

a) Scientific rationales

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? a) Start from client's knowledge, teach about diet modifications, and check for learning. b) Present the client with videos and books about diet changes that reduce inflammation. c) Ask the client's learning style, then teach diet information using that style. d) Answer the client's questions about diet alterations, and then evaluate understanding.

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

Which guideline should the nurse follow when including interventions in a plan of care? a) Make sure the nursing interventions are unrelated to the original outcomes. b) Date the nursing interventions when written and when the plan of care is reviewed. c) Make sure the attending physician approves of and signs the nursing interventions. d) Make sure each nursing intervention does not describe the action the nurse should perform.

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

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? a) Expect to modify the plan significantly. b) Individualize the plan to the client. c) Identify the appropriate nursing diagnoses. d) Include the rationale for the interventions.

b) Individualize the plan to the client.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? a) Nurses do not carry out physician-initiated interventions. b) Nurses do carry out interventions in response to a physician's order. c) Nurses are responsible for reminding physicians to implement orders. d) Nurses are not legally responsible for these interventions.

b) Nurses do carry out interventions in response to a physician's order.

A computerized information system developed to classify client outcomes is the: a) NANDA-International list b) Nursing Outcome Classification system c) International Classification of Diseases d) Clinical Care Classification System

b) Nursing Outcome Classification system

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? a) Consult with another nurse. b) Seek research about the disorder. c) Follow institutional guidelines. d) Set priorities using client care standards.

b) Seek research about the disorder.

The nurse recognizes that an example of a cognitive outcome is: a) The client demonstrates self-catheterization using clean technique by June 3. b) The client identifies three foods high in potassium by August 8. c) The client accurately measures the radial pulse for 1 minute by February 2. d) The client verbalizes increased confidence in testing glucose levels.

b) The client identifies three foods high in potassium by August 8.

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client? a) Posting the sign "NPO after midnight" over the bed b) Updating the diet orders in the client's plan of care c) Obtaining written consent for the diagnostic procedure d) Adding the diagnosis "Altered Nutrition, Less Than Required"

b) Updating the diet orders in the client's plan of care

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: a) identifies the unhealthy response preventing desired change. b) identifies factors causing undesirable response and preventing desired change. c) suggests client goals to promote desired change. d) identifies client strengths.

b) identifies factors causing undesirable response and preventing desired change.

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? a) "Client will learn to cope more effectively." b) "Client will list positive coping strategies and use them." c) "Client will identify one coping strategy to try by end of week." d) "Client tries using relaxation as a means to cope."

c) "Client will identify one coping strategy to try by end of week."

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? a) Client reports no headache. b) Client is drowsy after lunch. c) Client is normotensive. d) Client lipids are within range.

c) Client is normotensive.

Which is an appropriate expected outcome for a client? a) By the next clinic visit, client will report taking antihypertensive medication. b) After attending sibling classes, client will be happy about a new baby and demonstrate feeding. c) Client will ambulate safely with walker in the room within 3 days of physical therapy. d) Client will perform complete ostomy care while bathing on the second postoperative day.

c) Client will ambulate safely with walker in the room within 3 days of physical therapy.

Which outcome for a client with a new colostomy is written correctly? a) Explain to the client the proper care of the stoma by 3/29/20. b) The client will know how to care for the stoma by 3/29/20. c) The client will demonstrate proper care of the stoma by 3/29/20. d) The client will be able to care for stoma and cope with psychological loss by 3/29/20.

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

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? a) "I will take insulin until my blood sugar levels are normal." b) "I will take my medications between meals for maximum effect." c) "I will mix insulin glargine with insulin lispro at bedtime." d) "I will test my glucose level before meals and use sliding scale insulin."

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

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's and family's ability to cope. What action should the nurse take with this client? a) Provide more information about diabetes. b) Test the client's blood glucose levels. c) Ask the client whether anyone else in the client's family also has diabetes. d) Comfort the client and family.

d) Comfort the client and family.

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? a) Surveillance b) Maintenance c) Supervisory d) Educational

d) Educational

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? a) Initial b) Ongoing c) Discharge d) Standardized

d) Standardized

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client? a) The client will express an understanding of strategies for managing fatigue and shortness of breath. b) The client will ambulate 100 feet without supplementary oxygen or mobility aids. c) The client will demonstrate the correct use of a metered-dose inhaler. d) The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath.

d) The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath.

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: a) support system b) medical orders c) past medical history d) condition

d) condition

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) A standardized care plan b) An order set c) Guidelines d) An algorithm

a) A standardized care plan

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: a) discharge planning b) initial planning c) ongoing planning d) comprehensive planning

a) discharge planning

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? a) Ongoing b) Initial c) Discharge d) Outcome

a) Ongoing

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? a) The nurse has not made any error in writing the outcome. b) The nurse has omitted the time frame. c) The nurse has omitted the defining characteristics. d) The outcome should indicate what the nurse will do.

b) The nurse has omitted the time frame.

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? a) Interrupted Breastfeeding b) Ineffective Thermoregulation c) Altered Gas Exchange d) Impaired Parenting

c) Altered Gas Exchange

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? a) Tell another nurse about this client statement. b) Encourage the client to join a therapy group. c) Add the nursing diagnosis: Risk for Self-Harm. d) Document that the depression has resolved.

c) Add the nursing diagnosis: Risk for Self-Harm.

The nurse is determining realistic nursing interventions for a client on bed rest after a colon resection. What interventions would best meet the needs of this client? Select all that apply. a) Assist the client with deep breathing exercises with the use of incentive spirometry every hour. b) Assist the client with ambulation when the client feels better. c) Turn the client and change position every 2 hours. d) Administer acetaminophen every 6 hours for treatment of pain. e) Provide the client with a pillow to splint the abdomen and assist with coughing every 2 hours.

a) Assist the client with deep breathing exercises with the use of incentive spirometry every hour. c) Turn the client and change position every 2 hours. e) Provide the client with a pillow to splint the abdomen and assist with coughing every 2 hours.

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision? a) The client will understand the effects of smoking related to heart disease. b) By 08/02, the client will state three therapeutic methods of reducing stress. c) By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. d) By 8/02, the client will state when to notify the health care provider after discharge

a) The client will understand the effects of smoking related to heart disease.

Which is an example of a psychomotor outcome? a) Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. b) Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. c) The client will verbalize understanding of the need to continue to take medications as prescribed. d) The client's skin will remain smooth, moist, and without breakdown or ulceration.

a) Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

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? a) "You need to stop smoking for us to effectively combat this disease." b) "Please tell me your thoughts about treating this diagnosis." c) "Do you want to be discharged without treatment?" d) "What are your plans after discharge?"

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

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs? a) Seeking input from the client regarding preferences for a snack b) Cutting up food and opening drink containers for the client c) Providing the mother the phone number for the Poison Control Center d) Assisting the client to validate feelings regarding treatment options

b) Cutting up food and opening drink containers for the client

The nurse is developing goals for a newly admitted client with visual and auditory hallucinations. Which outcome is the priority for the client? a) Client will understand that the hallucinations aren't real in therapy sessions before discharge. b) Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior. c) Client will verbalize side effects of antipsychotic medications within 24 hours. d) Within 2 days, client will perform personal hygiene without reminders.

b) Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior.

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer? a) By the next clinic visit, the client will report needing antiemetic medication. b) After attending a cancer support group, the client will report being in a good mood. c) By discharge, the client will perform hand hygiene before and after port care. d) The client will schedule radiation therapy sessions and plan for chemotherapy.

c) By discharge, the client will perform hand hygiene before and after port care.

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? a) Septic workup due to blood pressure and heart rate elevation b) Isolation for suspected respiratory illness c) Narcotic analgesic to treat pain d) Acetaminophen to treat pain and fever

c) Narcotic analgesic to treat pain

Which statement correctly describes a nurse-initiated intervention? a) Nurse-initiated interventions require a physician's order. b) Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. c) Nurse-initiated interventions are derived from the nursing diagnosis. d) Nurse-initiated interventions are actions performed to diagnose a medical problem.

c) Nurse-initiated interventions are derived from the nursing diagnosis.

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? a) Process b) Structure c) Outcome d) Cost-effectiveness

c) Outcome

A nurse plans a series of muscle-strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. Which action by the nurse may have led to failure to meet the outcome? a) Failing to update the written plan of care b) Beginning the plan without family to help c) Stating outcomes too broadly d) Choosing actions that do not solve the problem

d) Choosing actions that do not solve the problem

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? a) The nurse will help the client ambulate the length of the hallway once a day. b) Offer to help the client walk the length of the hallway each day. c) The client will become mobile within a 24-hour period. d) Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

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