320 chapter 16

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

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

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

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

A nurse identifies the following nursing diagnosis for a client with an infected leg ulcer: "Deficient Knowledge related to diminished peripheral circulation and wound care as evidenced by recurrent infected leg ulcer." Which statement would the nurse identify as addressing a cognitive outcome? "The client states the reason for wound care measures." "The client demonstrates how to irrigate leg wound." "Client chooses correct size of dressing to cover the wound." "Client verbalizes being motivated to continue follow-up to prevent recurrence."

"The client states the reason for wound care measures."

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. Tell another nurse about this client statement. Encourage the client to join a therapy group. Document that the depression has resolved.

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 reports no headache. Client is drowsy after lunch. Client is normotensive. Client lipids are within range.

Client is normotensive.

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

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

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

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 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? Choosing actions that do not solve the problem Failing to update the written plan of care Beginning the plan without family to help Developing the plan without client input

Developing the plan without client input

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

Educational

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? Encourage hourly use of the incentive spirometer. Promote oral fluid intake between meals. Provide oral pain medication before ambulation. Reassess in 4 hours and document the findings.

Encourage hourly use of the incentive spirometer.

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. Expect to modify the plan significantly. Identify the appropriate nursing diagnoses. Include the rationale for the interventions.

Individualize the plan to the client.

Which are characteristics of appropriate client outcome statements? Select all that apply. Measurable Short-term Realistic Specific Broad in scope

Measurable Realistic Specific

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? Narcotic analgesic to treat pain Septic workup due to blood pressure and heart rate elevation Isolation for suspected respiratory illness Acetaminophen to treat pain and fever

Narcotic analgesic to treat pain

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

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

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

Nursing Outcome Classification system

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 Initial Discharge Outcome

Ongoing

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. The nurse will help the client ambulate the length of the hallway once a day. Offer to help the client walk the length of the hallway each day. The client will become mobile within a 24-hour period.

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

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

Seek research about the disorder.

A client has just given birth to a stillborn infant. The client is sobbing and says God is punishing the client for some bad choices in the past. The client reports having always believed in God as a loving and caring presence in life but now feeling that the client's faith is destroyed. Which nursing diagnoses would be appropriate for the nurse to include in this client's care plan? Select all that apply. Spiritual Distress Risk for Suicide Defensive Coping Impaired Parenting Grieving

Spiritual Distress Grieving

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

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

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? The client will understand the effects of smoking related to heart disease. By 08/02, the client will state three therapeutic methods of reducing stress. By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. By 8/02, the client will state when to notify the health care provider after discharge

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

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 not made any error in writing the outcome. The nurse has omitted the time frame. The nurse has omitted the defining characteristics. The outcome should indicate what the nurse will do.

The nurse has omitted the time frame.

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: support system. medical orders. past medical history. condition.

condition.

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

discharge planning.

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

involvement of the client and family.

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

Psychomotor

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. Present the client with videos and books about diet changes that reduce inflammation. Ask the client's learning style, then teach diet information using that style. Answer the client's questions about diet alterations, and then evaluate understanding.

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

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 An order set Guidelines An algorithm

A standardized care plan

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

Altered Gas Exchange

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? The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. The client will express an understanding of strategies for managing fatigue and shortness of breath. The client will ambulate 100 feet without supplementary oxygen or mobility aids. The client will demonstrate the correct use of a metered-dose inhaler.

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

What behaviors reflect planning? Select all that apply. The nurse decides to assist the client with ambulation in the hallway twice per shift. The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. The nurse considers the developmental level of the client when selecting education materials. The nurse assesses the client's usual sleep routine. The nurse assists the client with bathing, grooming, and dressing.

The nurse decides to assist the client with ambulation in the hallway twice per shift. The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. The nurse considers the developmental level of the client when selecting education materials.

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

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

The nurse has established client outcomes and outcome criteria. What should the nurse do next? Establish priorities Write a client plan of care Determine client goals Identify objectives

Write a client plan of care

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

identifies factors causing undesirable response and preventing desired 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? "You need to stop smoking for us to effectively combat this disease." "Please tell me your thoughts about treating this diagnosis." "Do you want to be discharged without treatment?" "What are your plans after discharge?"

"Please tell me your thoughts about treating this diagnosis." - what are your plans after discharge is too broad

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? Choosing actions that do not solve the problem Failing to update the written plan of care Beginning the plan without family to help Stating outcomes too broadly

Choosing actions that do not solve the problem

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? Initial Ongoing Discharge Standardized

Standardized

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 Psychosocial Coordinating Supervisory

Supportive

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? A plan designed to support the client physically A plan derived from a consensus of opinions of all staff members A plan with problems that are easily solved A plan made in conjunction with the hospital's ethics committee

A plan designed to support the client physically

What are specific measurable and realistic statements of goal attainment? Nursing diagnoses Nursing interventions Evaluations Outcomes

Outcomes

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 Once the client has received a discharge order As soon as possible after the client's surgery Once the client is admitted to the nursing unit from postanesthetic recovery

On the client's admission to the hospital

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

Nurse-initiated interventions are derived from the nursing diagnosis.

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem? Client will alternate rest periods with exercise throughout the day. Client will increase protein intake in small frequent meals. Client will use oxygen by nasal cannula when short of breath. Client will consistently perform pulmonary exercises.

Client will consistently perform pulmonary exercises.

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. Client will eat small meals of bland foods for 3 days. Client will identify the food that caused the condition within 3 hours. Client will maintain adequate hydration within 2 days.

Client will have formed stools within 24 hours.

Which is an example of a nurse-initiated intervention? Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. Administer oxygen at 4 L/min per nasal cannula. Administer a 1000-mL soap suds enema. Teach the client how to splint an abdominal incision when coughing and deep breathing.

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