Chapter 16: Nursing Assessment Chapter 17: Nursing Diagnosis Chapter 18: Planning Nursing Care Chapter 19: Implementing Nursing Chapter 20: Evaluation

A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statementRisk for loneliness related to impaired verbal communication?

Provide the patient with a writing board each shift.

The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?

Psychomotor

Which initial intervention is most appropriate for a patient who has a new onset of chest pain?

Reassess the patient.

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?

Problem-oriented assessment

The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?

"Begin with the highest priority diagnoses, then select appropriate interventions."

Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

"How many bowel movements a day have you had?"

A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?

"I'll wear the blue dress. It matches my eyes."

A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?

"Nurses use evaluation to determine the effectiveness of nursing care."

A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided?

"This system can help medical students determine the cost of the care they provide to patients."

Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?

"Validation involves comparing data with other sources for accuracy."

The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?

"What reasons do you think are contributing to your fatigue?"

A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?

Abdominal distention

The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?

Absence of skin breakdown

While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?

Ask the patient about usual sleep patterns and the onset of having difficulty resting.

While completing an admission database, the nurse is interviewing a patient who states "I am allergic to latex." Which action will the nurse take first?

Ask the patient to describe the type of reaction.

A patient visiting with family members in the waiting area tells the nurse "I don't feel good, especially in the stomach." What should the nurse do?

Ask the patient to return to the room, so the nurse can inspect the abdomen.

A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?

Dependent

Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?

Determines whether an intervention is correct and appropriate for the given situation

A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?

Develop good communication skills.

A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?

Developing nursing diagnoses before completing the database

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

Diagnosis

A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?

Disruption of tissue integrity

A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate?

Health behavior

A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?

Health promotion

A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene?

Hemorrhage

A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?

Impaired gas exchange related to alveolar-capillary membrane changes

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan?

Impaired skin integrity

A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?

Implementation

Which action indicates the nurse is using a PICOT question to improve care for a patient?

Implements interventions based on scientific research

A hospital's wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient's dressing changes. Which action should the nurses take next?

Include dressing change instructions and frequency in the care plan.

The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?

Protocols assist the clinician in making decisions and choosing interventions for specific health care problem/ conditions.

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?

Interdependent

The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?

Interpersonal

A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?

Involve the son in the plan of care as much as possible.

Which information indicates a nurse has a good understanding of a goal?

It is a broad statement describing a desired change in a patient's behavior.

The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Whichpriority action will the nurse take?

Measure the wound and observe for redness, swelling, or drainage.

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

Medicate the patient to alleviate discomfort while ambulating.

A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?

Observe wound appearance and edges.

The nurse is gathering data on a patient. Which data will the nurse report as objective data?

Respirations 16

The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action?

Revise the plan of care and change the dressing now.

A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?

States feels better after talking with family and friends

The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?

Teaches proper handwashing technique

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?

The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.

After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions?

To distinguish the nurse's role from the physician's role

A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statementImpaired skin integrity related to shearing forces?

Turn the patient every 2 hours, even hours.

A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)

a. Ambulating a patient b. Inserting a feeding tube c. Performing resuscitation e. Teaching about medications

A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)

a. Equipment b. Safe environment d. Assistive personnel

Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)

a. Perform dressing changes twice a day as ordered. b. Teach the patient about signs and symptoms of infection. c. Instruct the family about how to perform dressing changes. e. Administer medications to control the patient's blood sugar as ordered.

A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)

c. Adds objectivity to judging a patient's progress e. Measures nursing care on a national and international level

A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?

Ask about the chief concerns or problems.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make?

Ask the NAP to record the patient's vital signs before administering medications.

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations?

Ask the patient about the facial grimacing with movement.

Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action?

Assess the patient for other symptoms or problems, and then notify the health care provider.

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?

Assess the patient.

The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?

Assesses the patient's readiness for the procedure

Which action will the nurse take after the plan of care for a patient is developed?

Communicate the plan to all health care professionals involved in the patient's care.

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

Completes a comprehensive database

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Consider cultural differences during this assessment.

The nurse is intervening for a family member with role strain. Which direct care nursing intervention is mostappropriate?

Counseling about respite care options

A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document?

Decreased cardiac output related to altered myocardial contractility.

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?

Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?

Deficient fluid volume

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?

Diagnostic reasoning

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Etiology

A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient's plan of care?

Evaluate whether patient goals and outcomes have been met.

A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?

Evaluation

A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?

Evaluation

A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate?

Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals."

A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma 2. Writes a diagnostic label of impaired gas exchange 3. Organizes data into meaningful clusters 4. Interprets information from patient 5. Writes an etiology

1, 3, 4, 2, 5

A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take? 1. Identify the problem. 2. Discuss the findings and recommendation. 3. Provide the consultant with relevant information about the problem. 4. Contact the right professional, with the appropriate knowledge and expertise. 5. Avoid bias by not providing a lot of information based on opinion to the consultant.

1, 4, 3, 5, 2

A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

"Do you feel like you need to go to the bathroom?"

The nurse is revising the care plan. In which order will the nurse perform the tasks, beginning with the first step? 1. Revise specific interventions. 2. Revise the assessment column. 3. Choose the evaluation method. 4. Delete irrelevant nursing diagnoses.

2, 4, 1, 3

A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?

Acute pain

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

Acute pain

A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?

Administer pain medication.

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

Administer the acetaminophen.

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error?

Assessment

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention ismost appropriate for the nursing diagnostic statement Risk for falls?

Assist patient into and out of bed every 4 hours or as tolerated

A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?

Focus on the patient's presenting situation.

A nurse is conducting a nursing health history. Which component will the nurse address?

Patient expectations

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

Patient will have one soft, formed bowel movement by end of shift.

A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?

Patient will increase activity level this shift.

A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information?

Perform a thorough nursing health history.

Which method of data collection will the nurse use to establish a patient's database?

Performing a physical examination

The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?

Planning

A nurse is reviewing a patient's care plan. Which information will the nurse identify as a nursing intervention?

Provide assistance while the patient walks in the hallway twice this shift with crutches.

A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?

Reassess the patient and situation.

After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient?

Reassess the patient's pain level in 30 minutes.

Which action should the nurse take first during the initial phase of implementation?

Reassess the patient.

A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?

Reflex urinary incontinence

A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?

The nurse speaks only to the patient's daughter.

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?

The patient is able to ambulate in the hallway with crutches.

A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?

The patient is apprehensive about discharge.

A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?

The patient will feed self at all mealtimes today without reports of shortness of breath.

The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care?

The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of the shift

The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?

The patient's room with the door closed

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)

a. Rank all the patient's nursing diagnoses in order of priority. d. Consider time as an influencing factor. e. Utilize critical thinking.

A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)

c. Impaired physical mobility related to incisional pain d. Nausea related to adverse effect of cancer medication

A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)

c. Patient describing excitement about discharge e. Patient's expression of fear regarding upcoming surgery

A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)

c. Reposition a patient who is on bed rest. d. Teach a patient preoperative exercises. e. Transfer a patient to another hospital unit.