Prep U - Ch 13 : Nursing Process
The expected outcome for a client with a new diagnosis of diabetes mellitus (DM) 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."
A client has just been taught about lowering cholesterol with diet and exercise. What is the best way to evaluate that the client understands the material?
Ask direct questions about the teaching plan.
Which of the following groups 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 infertility caused by endometriosis?
By discharge from the clinic, client will achieve full-term pregnancy.
The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal?
Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.
Which is an appropriate expected outcome for a client?
Client will ambulate safely with walker in the room within three days of physical therapy.
A client who was just fitted with a new artificial leg following a recent amputation tells the nurse, "I want to participate in a 5K race to raise money for wounded soldiers." Which client outcome is most appropriate?
Client will walk with prosthesis and assistive devise in one week.
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
A nurse is caring for a client who was admitted 2 days ago following surgery. The client has a temperature of 99.6°F (37.5°C) and diminished lung sounds in the posterior bases. What is the best action by the nurse?
Encourage hourly use of the incentive spirometer.
Which nursing action demonstrates the planning step of the nursing process in caring for a client?
Establishing a wound care routine with the client at home
The nurse is reviewing the critical pathway for a client and notices that variances have been identified and documented. The nurse understands that variances are monitored concurrently and retrospectively for continuous quality improvement. Which of the following would the nurse identify as a function of variance measurement?
Identify client problems early in hospitalization
The nurse recognizes that identifying outcomes/goals must include which of the following?
Involvement of the client and family
A nursing instructor is explaining the characteristics of different plans of client care to a group of nursing students. Which of the following would the instructor include as a major difference about the clinical plan of care as compared to an instructional plan of care?
Is a practical and concise format with less detail
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.
A nurse is developing a care plan for a client with a stroke and is including surveillance interventions. Which of the following would the nurse most likely include?
Monitoring blood pressure
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 nurse is writing goals for a patient who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this patient?
Over the next 24-hour period, the patient will walk the length of the hallway assisted by the nurse
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 his lunch and successfully drew up and administered his 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 client stops in the hall after walking 30 feet and tells the nurse, "I don't want to do anymore 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.
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
Which intervention does the nurse recognize as a collaborative intervention?
Teach the client how to walk with a three-point crutch gait.
A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority?
The need to feel good about oneself
Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes?
The nurse expresses the client outcome as a nursing 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.
A nurse is giving post-operative care to a client after knee arthroplasty. Which of the following is a possible short-term goal for this client?
To ambulate the client to a bedside chair
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 be 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.
The parent of a hospitalized toddler tells the nurse, "If my child uses the word 'toytoy' a bathroom trip is needed." What action by the nurse best communicates this information about basic care needs for the client?
Writing the information in the plan of care
A nurse assesses the vital signs of a patient who is one day postsurgery in which a colostomy was performed. The nurse then uses the data to update the patient plan of care. What are these actions considered?
ongoing planning
A nurse is planning care for patients in a physician's office. Which actions will the nurse perform during this step of the nursing process? (Select all that apply.)
• Establishing priorities • Identifying expected patient outcomes • Selecting evidence-based nursing interventions • Communicating the plan of nursing care
Which of the following is a correctly written client goal? Select all that apply.
• The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. • The client will identify five low-sodium foods by October 9. • The client will eat at least 75% of all meals by May 5.