Planning

Which duration reflects an appropriate time frame for achievement of a short-term goal? 1 week 2 weeks 1 month 6 months

1 week Short-term goals are usually achievable within 1 week. WRONG: 2 weeks A goal that is achievable in 2 weeks is considered a long-term goal. 1 month A goal that is achievable in 1 month is a long-term goal. 6 months A goal that is achievable in 6 months is a long-term goal.

Which strategies would the nurse use to promote individualization of the identified nursing interventions? Select all that apply. Consider patient assessment findings. Ensure interventions align with patient acceptance. Consult other professionals involved in the patient's care. Consider the underlying etiology and related factors. Select interventions based on experience with other patients. NOT SURE

Consider patient assessment findings. When selecting interventions, the nurse considers the patient assessment findings. Ensure interventions align with patient acceptance. The nurse works with the patient to identify the most reasonable and effective interventions. The nurse considers patient needs, priorities, and prior experiences to help ensure patient acceptance of interventions. Consult other professionals involved in the patient's care. The nurse consults with members of the health care team and considers their expertise and competency when selecting interventions. Consider the underlying etiology and related factors. The nurse considers underlying etiology and related factors to determine which interventions are likely to have an impact on these factors. WRONG: Select interventions based on experience with other patients. Interventions that worked for other patients may be harmful or ineffective if applied to the current patient without careful consideration of the patient's condition and history.

When a patient who needs to lose 60 lb (27 kg) wants to change the nurse's recommended goal from exercising for 30 minutes a day, four times per week to exercising for 15 minutes per day, two times a week, which action would the nurse take? Ask why the patient does not want to lose weight. Allow the patient to set any goal the patient wants. Tell the patient the goal will not work. Discuss personal factors influencing the patient's perspective.

Discuss personal factors influencing the patient's perspective. When working together to establish a mutually agreed-on goal, the nurse must consider the patient's unique situation. These personal factors can influence the patient's feelings about reasonable goals and interventions. WRONG: Ask why the patient does not want to lose weight. The patient has not expressed that they do not want to lose the weight, so asking a question on this topic would not apply. Allow the patient to set any goal the patient wants. The nurse needs to collaborate with the patient to set goals. The nurse's expertise is needed to set realistic goals. Tell the patient the goal will not work. Simply telling a patient a goal will not work sounds argumentative and may demotivate the patient.

Which components would the nurse include in a comprehensive plan of care? Select all that apply. Evaluation Interventions Measurable goals Medical diagnosis Nursing diagnosis NOT SURE

Evaluation Evaluation is a component of a nursing care plan. Interventions Interventions are a component of a nursing care plan. Measurable goals Measurable goals are a component of a nursing care plan. Nursing diagnosis Nursing diagnosis is a component of a nursing care plan. WRONG: Medical diagnosis Medical diagnosis is not a component of the nursing care plan.

Which statement about nursing interventions is accurate? Interventions are another term for health care provider orders. The nurse selects standardized interventions to promote safety. Interventions are activities that assist the patient in achieving goals. The nurse and the health care provider select the appropriate interventions for the patient.

Interventions are activities that assist the patient in achieving goals. Interventions are activities that assist the patient in achieving goals and improving health. WRONG: Interventions are another term for health care provider orders. Interventions are not synonymous with health care provider orders. Provider orders may include interventions. The nurse selects standardized interventions to promote safety. The nurse selects interventions that are individualized, not standardized, to ensure the most effective plan of care for each patient. The nurse and the health care provider select the appropriate interventions for the patient. The nurse works with the patient, family, caregivers, and other members of the health care team to select and individualize the interventions that will be most effective for the patient.

Match the nursing diagnosis to its prioritization. Life-threatening Clinically urgent Routine Impaired Tissue Integrity Impaired Sleep Impaired Airway Clearance

Life-threatening Impaired Airway Clearance Clinically urgent Impaired Tissue Integrity Routine Impaired Sleep

Which information would the nurse expect to find on a conceptual care map (CCM)? Select all that apply. Medications Pathophysiology Medical history Health care provider orders Nursing plan of care

Pathophysiology Pathophysiology is important for the nurse to understand and relate to the patient situation; however, it is not specifically included on the CCM. WRONG: Medications Medications are listed on the CCM and are used to identify appropriate nursing diagnoses, goals, and interventions. Medical history Pertinent medical history is on the CCM and is used to identify appropriate nursing diagnoses, goals, and interventions. Health care provider orders Health care provider orders are listed on the CCM and are used to identify appropriate nursing diagnoses, goals, and interventions. Nursing plan of care The nursing plan of care is found on the CCM and is used to identify appropriate nursing diagnoses, goals, and interventions.

Which goal is an example of a long-term goal for the patient? The patient will achieve wound healing in 3 weeks. The patient will have a pain level of less than 3 for 48 hours. The patient will demonstrate an increase in activity tolerance in 1 week. The patient's wound will decrease in dimension in 2 days.

The patient will achieve wound healing in 3 weeks. A goal achievable in 3 weeks is a long-term goal. WRONG: The patient will have a pain level of less than 3 for 48 hours. A goal achievable in 48 hours is a short-term goal. The patient will demonstrate an increase in activity tolerance in 1 week. A goal achievable in 1 week is a short-term goal. The patient's wound will decrease in dimension in 2 days. A goal achievable in 2 days is a short-term goal. However, this is an example of an expected outcome, not a goal, because a measurable change is included (decrease in dimension). Goals are broad statements, while outcomes are measurable changes that must be achieved to reach goals.

Place the components of the planning step of the nursing process in the correct order. Create a plan of care. Establish goals and outcomes. Select interventions. Prioritize nursing diagnoses.

The planning steps in order are as follows: prioritize nursing diagnoses, establish goals and outcomes, select interventions, and create a plan of care.

For a patient scheduled for knee surgery, which statement identifies when the planning step of the nursing process begins? After the surgery is complete When the patient is admitted to the hospital Just before being discharged from the hospital When the nurse contacts the patient to schedule surgery

When the nurse contacts the patient to schedule surgery Care planning begins when the patient and nurse first interact. Preadmission teaching is a significant planning responsibility for the office nurse who contacts the patient prior to surgery. WRONG: After the surgery is complete Care planning must begin before surgery is complete. When the patient is admitted to the hospital Inpatient care planning begins when the patient and nurse first interact in the hospital. Just before being discharged from the hospital Discharge planning begins upon the patient's admission.

Which action would the nurse implement to promote patient success through goal attainment? Ask what the patient would like to achieve. Identify the goal, and tell the patient what it is. Tell the patient the goal was ordered by the health care provider. Identify one goal reflecting the nurse's priority and another that reflects the patient's priority.

Ask what the patient would like to achieve. To be most effective in guiding care, goals must also include input from the patient and the patient's caregivers or family members. WRONG: Identify the goal, and tell the patient what it is.Although the nurse's input is essential to developing clinically sound goals and interventions, goals must also include input from the patient and the patient's caregivers or family members. Collaboration to create mutually agreed-on goals is important for goal attainment. Tell the patient the goal was ordered by the health care provider. Telling the patient what the health care provider ordered may help the patient establish a goal, but goals must also include input from the patient and the patient's caregivers or family members. Collaboration to create mutually agreed-on goals is important for goal attainment. Identify one goal reflecting the nurse's priority and another that reflects the patient's priority. Goals should not be based solely on the nurse's priority. The nurse should strive to create realistic goals in collaboration with everyone involved in the goal-setting process (nurse, patient, family members, caregivers, and health care team members), while ensuring that the goals adhere to clinical standards.

Which role would the nurse associate with selection of interventions during the planning step of the nursing process? Validation of nursing diagnoses Evaluation of the patient's goal attainment Facilitation of clear communication of patient needs Assistance for the patient in achieving goals and improving health NOT SURE

Assistance for the patient in achieving goals and improving health Interventions are activities that assist the patient in achieving goals and improving health. WRONG: Validation of nursing diagnoses Interventions describe actions that help patients achieve goals. They do not validate nursing diagnoses. Evaluation of the patient's goal attainment Expected outcomes, not interventions, establish measures that allow the nurse to evaluate goal attainment. Facilitation of clear communication of patient needs The purpose of nursing diagnoses, not interventions, is to facilitate clear communication of patient needs.

If the nurse collaborates with the patient when setting goals, which behaviors is the patient more likely to demonstrate? Select all that apply. Be aware of priority needs. Accept realistic goals. Allow the nurse to control care. Be more successful in achieving goals. Comply with interventions and behavior changes. NOT SURE

Be aware of priority needs. If the focus is on patient-centered care in goal setting, the patient is more likely to be aware of priority needs. Accept realistic goals. If the focus is on patient-centered care in goal setting, the patient is more likely to accept realistic goals. Be more successful in achieving goals. If the focus is on patient-centered care in goal setting, the patient is more likely to be successful in achieving goals. Comply with interventions and behavior changes. If the focus is on patient-centered care in goal setting, the patient is more likely to comply with interventions and behavior changes. WRONG: Allow the nurse to control care. If the focus is not on patient-centered care in goal setting, the patient is less likely to feel empowered and in control of their care.

Which statement is an example of a long-term patient goal? Dress independently within 6 months. Demonstrate deep-breathing techniques by end of shift. Report an increase in appetite within 1 week. Identify interventions to reduce risk for infection in 2 days.

Dress independently within 6 months. Goals that can be achieved in weeks to months are long-term goals. WRONG: Demonstrate deep-breathing techniques by end of shift. Goals that can be achieved in a shift (i.e., 12 hours) are short-term goals. Report an increase in appetite within 1 week. Goals that can be achieved in 1 week are short-term goals. Identify interventions to reduce risk for infection in 2 days. Goals that can be achieved in 2 days are short-term goals.

Match the component of the plan of care with the related information. Heart rate (HR) 34 beats/min Impaired Cardiac Function, supported by bradycardia HR will return to 60 to 90 beats/min in 48 hours; monitor cardiac rhythm continuously HR 70 to 79 beats/min × 48 hours; goal met; discontinue goal Evaluation Key assessment data Measurable goal and intervention Nursing diagnosis

Heart rate (HR) 34 beats/min Key assessment data Impaired Cardiac Function, supported by bradycardia Nursing diagnosis HR will return to 60 to 90 beats/min in 48 hours; monitor cardiac rhythm continuously Measurable goal and intervention HR 70 to 79 beats/min × 48 hours; goal met; discontinue goal Evaluation

Which nursing diagnosis would be ranked as the highest priority? Constipation Pressure Ulcer Impaired Gas Exchange Impaired Tissue Integrity

Impaired Gas Exchange It is essential that the nurse identify and immediately respond to patient situations that are potentially life-threatening, such as Impaired Gas Exchange. WRONG: Constipation Constipation is not life-threatening, so it would not be the highest priority. Pressure Ulcer Pressure Ulcer is not a life-threatening concern. Impaired Tissue Integrity Impaired Tissue Integrity may be urgent, but it is not life-threatening.

Which rationale explains the importance of outcome identification to the achievement of patient goals? Determines goal validity Indicates goal attainment Standardizes patient goals Tells the nurse which goals to measure

Indicates goal attainment Outcome identification sets specific measures used to evaluate effectiveness of meeting goals, indicating goal attainment. WRONG: Determines goal validity Outcome identification does not validate goals. Standardizes patient goals Goals are individualized, not standardized, to the specific patient. Tells the nurse which goals to measure All goals should have specific measures to evaluate effectiveness.

Which part of the plan of care contains the statement, "Patient will display complete healing of surgical area within 3 weeks"? Evaluation Interventions Measurable goal Nursing diagnosis

Measurable goal "Patient will display complete healing of surgical area within 3 weeks" is an example of a measurable goal. WRONG: Evaluation The patient's progress toward achieving the goal is evaluated during the evaluation step. An example of a statement that would be found in the evaluation component of the care plan is "Temperature 98.5°F after 48 hours. Goal met. Discontinue goal." Interventions Interventions are the activities taken to achieve the goal. "Monitor temperature every 2 hours" is an intervention. Nursing diagnosis The nursing diagnosis contains the nursing diagnostic label or patient problem. An example is Hyperthermia, supported by an oral temperature of 102.4°F (39°C).

Which type of planning would the office nurse perform when contacting a patient with information about what to expect before, during, and after a scheduled surgery? Discharge planning Home care planning Preadmission planning Inpatient care planning

Preadmission planning Preadmission planning occurs before testing or surgery. Patients learn what will happen and are better prepared for their health care experiences. WRONG: Discharge planning Discharge planning begins upon the patient's admission and continues until the patient is discharged. Home care planning Home care planning focuses on patient care needs in the home. Inpatient care planning Inpatient care planning occurs in the inpatient setting to support patient recovery.

Which actions are involved in the planning step of the nursing process? Select all that apply. Assessing the patient Prioritizing nursing diagnoses Developing patient-centered goals Creating a personalized plan of care Evaluating the patient's response to interventions

Prioritizing nursing diagnoses The planning step involves prioritizing the patient's nursing diagnoses. Developing patient-centered goals The planning step involves developing patient-centered goals. Creating a personalized plan of care The planning step involves creating a personalized patient plan of care. WRONG: Assessing the patient Patient assessment occurs during the assessment step of the nursing process. Evaluating the patient's response to interventions Evaluation of the patient's response to interventions occurs during the evaluation step of the nursing process

Which rationale supports the use of a conceptual care map (CCM) to develop a plan of care? Provides criteria for the selection of interventions Assists with the development of a standardized plan of care Lists all of the patient's medical history in a concise format Provides a quick, yet comprehensive, overview of the patient's status and plan

Provides a quick, yet comprehensive, overview of the patient's status and plan A CCM is a combination of both the care plan and a concept map and provides a comprehensive overview of the patient's status and plan. WRONG: Provides criteria for the selection of interventions Criteria for interventions are not included in the CCM. Assists with the development of a standardized plan of care The CCM contains patient information that helps the nurse create a plan of care that is individualized for the patient, not standardized for all patients. Lists all of the patient's medical history in a concise format The CCM contains the patient's pertinent medical history, not the patient's entire medical history.

Which statement describes the plan of care? Development of the plan of care is the first component in the planning step of the nursing process. The Joint Commission requires the plan of care to be part of the electronic health record. The plan of care summarizes the patient's condition, goals, and planned interventions. The plan of care is most effective when standardized to incorporate evidence-based practice.

The plan of care summarizes the patient's condition, goals, and planned interventions. The nursing plan of care is a document that summarizes the patient's condition, goals, and planned interventions for the patient. WRONG: Development of the plan of care is the first component in the planning step of the nursing process. The final component in the planning step is to create a plan of care for the patient. The first component involves developing patient goals and selecting interventions. The Joint Commission requires the plan of care to be part of the electronic health record. The Joint Commission requires development of a plan of care, but it does not mandate that it be part of the electronic health record. The plan of care is most effective when standardized to incorporate evidence-based practice. Some standardized care plans may be available as basic templates; however, all patients are required to have unique, patient-centered plans of care designed to meet their specific needs.

At which point would the nurse begin the planning stage of the nursing process? At patient discharge When the patient requires care When the patient and nurse first interact Upon patient admission to the hospital

When the patient and nurse first interact The planning step begins when the patient and nurse first interact, and it continues until the patient no longer requires care. WRONG: At patient discharge Discharge planning begins as soon as the patient is admitted, but the planning stage of the nursing process is ongoing and begins when the patient and nurse first interact. When the patient requires care The patient and nurse may interact before the patient requires care, such as during preadmission teaching. The beginning of the planning stage of the nursing process begins when the patient and nurse first interact. Upon patient admission to the hospital The patient and nurse may interact prior to the patient being admitted to the hospital, such as in an outpatient or office setting. Planning begins when the patient and nurse first interact.