Chapter 16

The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the best indicator that the outcome expectations have been met?

"I walk daily wearing low-heeled shoes."

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."

The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply.

After attending an infant care class, the client will correctly demonstrate the procedure for bathing her newborn. By 4/5/15, the client will demonstrate how to care for a colostomy. After counseling, the client will describe two coping measures to deal with stress.

A nurse is developing the postoperative plan of care for a client admitted with a fractured hip who has undergone surgery to repair it. Which intervention would the nurse identify as a nurse-initiated intervention? Select all that apply.

Assess the client's pain level every 2 hours. Turn the client every 2 hours per turning schedule. Teach the client how to perform relaxation as a pain relief strategy.

A nurse is caring for a client with a bowel obstruction that has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply.

Auscultate for bowel sounds. Begin feedings with clear broth. Consult with dietitian regarding appropriate foods.

The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. Which outcome statement is structured correctly?

By discharge from the fertility clinic, the client will achieve full-term pregnancy.

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.

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:

Condition

A nurse is planning nursing interventions for clients 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

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.

The nurse is caring for a 48-year-old male client with a new colostomy. Which client 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 client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?

Ongoing planning

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

A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse?

Perform hourly neurovascular assessment.

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

Psychomotor

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

Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?

Standardized

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.

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

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

The nurse is developing outcomes for the care plan of a client admitted with Parkinson's disease. The nurse will derive the outcomes for this client's care plan from:

The problem statement of 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 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

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.