Craven Ch. 14

Which action should the nurse perform during the planning phase of the nursing process?

Identify measurable goals or outcomes.

A nurse working in a critical care unit has formulated the following nursing diagnoses for a client. Which nursing diagnosis likely would be the priority?

Impaired Gas Exchange

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 is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client?

Ineffective Impulse Control

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

Make recommendations for revising the plan of care.

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.

Which elements are common to any type of plan of care? Select all that apply.

Nursing diagnoses Client goals Nursing interventions

Which is most important for the nurse to include in a client's plan of care?

Nursing interventions

Which outcome is correctly written?

On discharge, client will be able to list five symptoms of infection.

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

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.

Which are correctly written nursing interventions? Select all that apply.

Provide 5 to 6 small meals daily. Reposition the client from side to side every hour around the clock. Provide opportunities for the client to express concerns and verbalize feelings.

The nurse is planning the care of a client who is receiving treatment for acute renal failure and who has begun dialysis 3 times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of an arteriovenous fistula." This outcome is classified as which?

Psychomotor

A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement?

Return the client to bed and provide pain relief measures.

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?

Scientific rationales

Which action should the nurse perform during the planning step of the nursing process?

Selects nursing measures, including client education

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.

Which intervention does the nurse recognize as a collaborative intervention?

Teach the client how to walk with a three-point crutch gait.

In planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2016." Why is this outcome inadequate?

The chosen verb is not observable or measurable.

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?

The client will ambulate with assistance by the nurse to a bedside chair.

Which is an example of a long-term goal for a client with asthma?

The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

A resident of a long-term care facility refuses to eat until the client has had hair combed and makeup applied. In this case, what client need should have priority?

The need to feel good about oneself

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 formulates the following client outcome: "Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7." Which error has the nurse made?

The nurse included more than one client behavior in the outcome.

Which nursing intervention is the most clear and well-written?

The nurse will offer the client 100 mL of water every 2 hours while the client is awake.

What is the primary purpose of the outcome identification and planning step of the nursing process?

To design a plan of care for and with the client

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

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent?

Verb (action)

A nursing student is developing an outcome criterion for an assigned client. The student demonstrates understanding by including information that answers which questions? Select all that apply.

Who What actions Under what circumstances How well When

Which is an example of a psychomotor outcome?

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?

Write a client plan of care

The nurse reviews the plan of care for the client who experienced a left hip replacement to determine the day's care guidelines and outcomes. The type of plan of care the nurse is reviewing is a(n):

clinical pathway.

A benefit of using computerized plans of nursing care is:

reduction in the time spent on care planning.

The nurse should derive the outcomes for a client's care plan from:

the problem statement of the nursing diagnosis.

A nurse is preparing to write client outcomes for a plan of care. Which verb would be least appropriate to use when writing the outcomes?

understands

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."

A client is scheduled to be fitted with a prosthesis following the loss of the nondominant hand after a traumatic injury. Nurses have documented an outcome that states, "After attending multiple educational sessions, the client will demonstrate correct technique for applying the prosthesis." Which statement by the client would indicate a need to revise the plan of care related to this outcome?

"I'm not interested in wearing an artificial hand."

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."

Which is a physician-initiated intervention?

Administer oxygen at 4 L/min per nasal cannula.

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?

Altered Gas Exchange

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.

The nurse is caring for Isabel, a 45-year-old ventilator-dependent quadriplegic. The nurse is in the process of placing IV access when the ventilator alarms occlusion. The nurse assesses Isabel, and she appears mildly uncomfortable but is not in acute distress. What is the nurse's priority in the nursing outcome planning?

Assess tracheostomy for patency.

Which group of terms best describes a nurse-initiated intervention?

Autonomous, clinical judgment, client outcomes

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer?

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

Which client outcome requires modification?

By the end of instruction, client will know how to perform dressing changes.

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

Which elements are important to incorporate into a client's plan of care? Select all that apply.

Client participation Care that is realistic and measurable Involvement of support people

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.

Which is an appropriate expected outcome for a client?

Client will ambulate safely with walker in the room within 3 days of physical therapy Client will independently follow transplant medication schedule 1 week after surgery.

Which outcome illustrates a common error nurses make when writing client outcomes?

Client will be less anxious and fearful before and after surgery.

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.

The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply.

Client will increase nutrition, eating 75% of meals. Client will report pain is controlled at or below 3 of 10. Client will perform dressing change independently.

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem?

Client will not leave the premises without a caregiver.

Which outcome is sufficiently measurable?

Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020.

What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system?

Clinical pathways

Which type of care plan is most likely to enable the nurse to take a holistic view of the client's situation?

Concept map care plan

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.

What should the nurse do to make outcomes more achievable?

Encourage the client and family to be involved in the development of outcomes.

Which is a common error nurses make when writing client outcomes?

Expressing the client outcome as a nursing intervention

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

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

As part of an assignment, a nursing student is asked to create a concept map for a client. The student asks the instructor, "Why is this necessary? Isn't the plan of care enough?" Which response by the instructor would be most appropriate?

"The map helps you to think more critically about the relationship between concepts."

For which client would a standardized plan of care most likely be appropriate?

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia

Which is inappropriate to include in an outcome?

A flexible time frame

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 clonidine according to the standardized plan of care for a client admitted with hypertension. Which assessment information deviates from the expected client outcome for the first 24 hours and requires nursing intervention?

Client gains 1 kg (2.2 lb) in 1 day

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.

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?

Comfort the client and family.

A nurse is developing short-term outcomes for a client with a nursing diagnosis of "Deficient Knowledge related to insulin self-administration as evidenced by statements of therapy being new and never having done it before." When writing the outcomes, which verbs would the nurse use to achieve a psychomotor change in behavior? Select all that apply.

Demonstrate Choose

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?

Developing the plan without client input

What common problem is related to outcome identification and planning?

Failing to involve the client in the planning process

These nursing diagnoses appear on a client's care plan. In what order will the nurse prioritize them?

Impaired Swallowing Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image

A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care?

Include the client and the client's power of attorney in the discussion.

A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered?

Ongoing planning

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?

Standardized

A client is on the surgical unit following resection of an intestinal tumor. The client is alert and oriented x3. Based on an assessment of the client, the physician writes a medical order to "ambulate with assistance" in the chart. This will be the client's first time ambulating. Which is the best nursing outcome for this client?

The client will ambulate with the assistance of a walker without falling within the next 4 hours.

Which are correctly written client goals? Select all that apply.

The client will identify five low-sodium foods by October 9. The client will rate pain as a 3 or less on a 10-point scale by 1700 today. The client will eat at least 75% of all meals by May 5.

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.

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.

Which actions occur during the initial planning of client care? Select all that apply.

The nurse who performs the admission nursing history and physical assessment makes the initial plan. After the initial plan is developed, the nurse prioritizes nursing diagnoses. The nurse identifies client goals and the related nursing care in the initial plan.

Which part of the nursing diagnosis does an outcome derive from?

The problem statement

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using:

assessment skills.

A client's care plan contains the following information. Which would the nurse identify as the client outcome criteria?

demonstrates coughing exercises at next session

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

A nurse is developing a care plan for a client with a stroke and is including surveillance interventions. What would the nurse most likely include?

monitoring blood pressure

The nurse has identified short- and long-term goals for a client after surgery to remove a leg tumor. When determining interventions for the goals, which questions are important for the nurse to consider? Select all that apply.

Are the interventions compatible with other planned therapies? Are the interventions evidence-based? Are the interventions realistic and do they require resources available to the nurse? Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background?

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

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

A nurse has identified on the plan of care for a client a nursing diagnosis of "Anxiety related to concerns about cancer treatment as evidenced by client's statement." One of the interventions that the nurse writes on the plan of care is to encourage the client to verbalize his feelings about the diagnosis and its effect on his quality of life. The nurse has identified which type of nursing intervention?

Psychosocial

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to lunch and successfully drew up and administered the insulin while the nurse observed. How should the nurse follow up this observation?

Record an evaluative statement in the client's plan of care.

A nurse administers colchicine according to the standardized plan of care for a client admitted with acute gouty arthritis of the right great toe. Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention?

Foot remains red and swollen.

Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal?

Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.