ADN 001 PrepU Ch 16

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.

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 normotensive

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.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

A computerized information system developed to classify client outcomes is the:

Nursing Outcome Classification system

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 treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention

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."

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 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 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. Explanation: Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable. The verbs in the distractors are all measurable. The correct response has a goal that the nurse will be unable to measure.

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?

Updating the diet orders in the client's plan of 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?

Narcotic analgesic to treat pain

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 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. Explanation: Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal.

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed. Explanation: Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The physician does not approve and sign the interventions, because they are nursing interventions.

A fully measurable outcome should include:

a subject, verb, conditions, performance criteria, and target time (though not every outcome requires each parameter)