yoost chapter 5
All nursing interventions that are implemented for patients must be documented or charted. Proper documentation of interventions:a.facilitates communication with all members of the health care team.b.are only considered "legal" if documented in the paper chart.c.leads to errors of omission and repetition of care.d.does not directly measure goal achievement or outcomes.
A All nursing interventions that are implemented for patients must be documented or charted. In some cases, this may involve checking off an intervention in the patient's EMR designed to track the effectiveness of specific interventions. Many health care agencies have special requirements for documenting interventions such as the use of physical restraints or pain protocols. Proper documentation of interventions facilitates communication with all members of the health care team and provides an essential legal record. Accurate charting helps to alleviate omissions and repetition of care. Documentation also allows nurses to evaluate the effectiveness of nursing interventions in meeting patient goals and outcomes, which is the final step in the nursing process.
A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process?a.Assessmentb.Planningc.Implementationd.Evaluation
A During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse is caring for a patient diagnosed with Lyme disease. The patient tells the nurse, "My heart seems to be skipping some beats. My doctor told me to let the nurse know if this happens since it might be a complication of my disease." The nurse auscultates the heart and confirms the palpitations. Which step of the nursing process does the nurse's action demonstrate?a.Assessmentb.Planningc.Implementationd.Evaluation
A During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The health history is conducted in which step of the nursing process?a.Assessmentb.Diagnosisc.Implementationd.Evaluation
A During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process?a.Assessmentb.Planningc.Implementationd.Evaluation
A During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse develops a list of nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, "I understand that I will lose most of my hair. Will it grow back?" Which of the following diagnoses will have the highest priority?a.Disturbed body imageb.Nauseac.Risk for bleedingd.Imbalanced nutrition: less than body requirements
A Priority of nursing diagnoses is determined by the patient's preference as well as the severity of the symptoms. The patient is concerned about the loss of hair because this will affect body image. For her, this is a prime focus. The patient may experience nausea as a result of the chemotherapy drugs. The patient will not be able to eat properly if the nausea is not controlled thus decreasing nutritional intake. There is a potential for bleeding as a result of the low platelet count created by the drugs. All of these must be addressed, but the primary diagnosis, in this case, would be body image.
The nursing process is the foundation of professional nursing practice. As such, the nursing process can be defined as:a.The framework that nurses used to provide care.b.A complex process during which nurses think about their thinking.c.The process that allows nurses to collect essential data. d.Thinking like a nurse in developing plans of care.
A The nursing process is the foundation of professional nursing practice. It is the framework within which nurses provide care to patients in an organized and effective manner. Paul describes critical thinking as a complex process during which individuals think about their thinking to provide clarity and increase precision and relevance in a specific situation while attempting to be fair and consistent. Critical thinking using the nursing process allows nurses to collect essential patient data, articulate the specific needs of individual patients, and effectively communicate those needs, realistic goals, and customized interventions with members of the health care team. Thinking like a nurse is facilitated by nurses using the nursing process in the development of individualized patient plans of care.
Which of the following is a correctly written nursing diagnosis appropriate for a patient's plan of care?a.Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds.b.Imbalanced nutrition: less than body requirements.c.Impaired physical mobility related to contractures.d.Risk for suffocation related to smoking in bed as evidenced by absent breath sounds.
A There are three types of diagnoses: actual, risk, and health-promotion. Actual diagnoses have three parts: problem, etiology, and signs/symptoms. Risk diagnoses include only the identified need and the risk factors. The nursing diagnosis, imbalanced nutrition: less than body requirements, is missing the problem, etiology, and signs and symptoms. Impaired physical mobility is missing the evidence. Risk for suffocation should have only two parts. There are no signs and symptoms if the patient is at risk.
The nurse is attempting to develop nursing diagnoses for her patient. The nurse understands that nursing diagnoses: (Select all that apply.)a.identify actual or potential problems as well as responses to a problem.b.require naming patient problems using nursing diagnostic labels.c.utilize objective data since subjective data are often inaccurate.d.includes unvalidated data to determine an accurate and thorough diagnosis.e.are similar to medical diagnoses since they both are labels for diseases.
A, B The nursing diagnosis identifies an actual or potential problem or response to a problem. Accurate identification of nursing diagnoses for patients results from carefully analyzing, validating, and clustering related patient subjective (symptoms) and objective (signs) data. If data collection includes inaccurate or inadequate information or if data are not validated or clustered with related information, a patient may be misdiagnosed. Diagnosis in the nursing process requires naming patient problems using nursing diagnostic labels. Medical diagnoses are labels for diseases, whereas nursing diagnoses describe a response to an actual or potential problem or life process.
Establishing short- and long-term goals to address nursing diagnoses involves: (Select all that apply.)a.discussion with the patient.b.exclusion of family with making patient decisions.c.collaboration with other members of health care team.d.making the health care provider as the central figure.e.coordination of care as collaborative care.
A, C, E Establishing short- and long-term goals to address nursing diagnoses involves discussion with the patient and often requires collaboration with family members and other members of the health care team. Coordinated, team-based patient care is called collaborative care. The patient's health care team members may include several nurses: the primary care provider; medical or surgical specialists; respiratory therapists; a dietitian; a physical therapist; occupational, music, or art therapists; a spiritual adviser; and social workers. The patient's primary nurse is often the central figure in coordinating collaborative care.
The nurse is admitting a patient experiencing chest discomfort and shortness of breath. The patient also has a history of stroke. The nurse documents the nursing diagnosis "Risk for stroke related to history of stroke." The risk factor for this patient is:a.stroke.b.history of stroke.c.chest discomfort.d.shortness of breath.
B A two-part risk nursing diagnostic statement contains only (1) the patient's identified need or problem (i.e., NANDA-I nursing diagnostic label) and (2) factors indicating vulnerability (i.e., risk factors). The risk factor is the history of stroke. The chest discomfort and shortness of breath are symptoms of the current problems and would not be documented as potential or "risk" issues. "Stroke" would be the identified potential problem.
The nurse writes a short-term goal for a patient scheduled for surgery in the morning. The goal that contains all of the necessary elements is:a.The patient will walk to the bathroom within 48 hours after surgery.b.The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery.c.The patient will walk to the bathroom without experiencing shortness of breath.d.The patient will walk to the bathroom without experiencing shortness of breath after surgery.
B All short- and long-term goals must be (1) patient focused, (2) realistic, and (3) measurable. For example, a patient-focused, realistic, and measurable short-term goal may be written for a patient with the nursing diagnosis of Activity Intolerance: The patient walks to the bathroom without experiencing shortness of breath within 48 hours after surgery.
In which step of the nursing process does the nurse prioritize the nursing diagnoses and identify interventions to address the patient goals?a.Assessmentb.Planningc.Implementationd.Evaluation
B During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nursing student is caring for a patient admitted with severe anemia. The patient receives two units of packed red blood cells and tells the student, "I am feeling so much better. I'm not so tired anymore and can bathe myself." The student reviews the patient goal "report an increase in activity tolerance" and concludes that the patient's goal has been met and adjusts the patient's plan of care. This is an example of nursing process:a.organization.b.dynamics.c.adaptability.d.collaboration.
B The nursing process is cyclic rather than linear. As an individual patient's condition changes, so does the way a professional nurse thinks about that patient's needs, forcing modification of earlier plans of care. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any setting and at every level of care. The plan of care is individualized for the patient on the basis of assessment findings, changing needs, setting, and timing of interaction, not just outcomes. Following the steps of the nursing process ensures that patient care is well organized and thorough. Collaboration among several members of the health care team is often required to adequately address patient needs. In many cases, nurses incorporate orders from a primary care provider, nursing interventions, and input from others, such as physical therapists, social workers, or respiratory therapists, into a patient's plan of care to help alleviate patient problems and achieve established patient-centered goals and outcomes.
Which of the following statements would be considered objective data? (Select all that apply.)a."I'm short of breath."b."Blood pressure 90/68, apical pulse 102, skin pale and moist."c."Lung sounds clear bilaterally, diminished in right lower lobe."d."I feel weak all over when I exert myself."e."My pain level is down to 2. It was 8."
B, C Data collected from medical records, laboratory, and diagnostic test results, or physical assessments are objective. Objective data (i.e., signs) consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested. Subjective data (i.e., symptoms) are spoken. Patients' feelings about a situation or comments about how they are feeling are examples of subjective data. Data shared by a source verbally are considered subjective. Subjective data may be difficult to validate because they cannot be independently and objectively measured.
The nurse is assisting a patient to bed when the patient says, "My chest hurts and my left arm feels numb. What's wrong with me?" What is the type and source of data obtained from the patient's complaint?a.Objective data from a primary sourceb.Objective data from a secondary sourcec.Subjective data from a primary sourced.Subjective data from a secondary source
C Patients' feelings about a situation or comments about how they are feeling are examples of subjective data. Data shared by a source verbally are considered subjective. Subjective data may be difficult to validate because they cannot be independently and objectively measured. Data collected from medical records, laboratory, and diagnostic test results, or physical assessments are objective. Objective data (i.e., signs) consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested. Subjective data (i.e., symptoms) are spoken. Primary data consist of information obtained directly from a patient. Secondary data are collected from family members, friends, other health care professionals, or written sources such as medical records and test results.
A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. The nurse asks the manager if there is a document written by the physician for this type of reaction. The nurse is referring to a:a.protocol.b.clinical pathway.c.standing order.d.care map.
C Standing orders are written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when care is common to a certain type of situation, such as what to do if a patient experiences chest pain or what actions to take after a colonoscopy. Protocols are written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician's order. Health care agencies have established protocols outlining procedures for admitting patients or handling routine care situations. Clinical pathways, sometimes referred to as care pathways, care maps, or critical pathways, are multidisciplinary resources designed to guide patient care.
During a patient's bath, the nurse observes the patient having a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process?a.Assessmentb.Planningc.Implementationd.Evaluation
C The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing?a.Assessmentb.Diagnosisc.Implementationd.Evaluation
C The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The community health nurse is applying the nursing process to the care of patients with coronary artery disease. The nurse determines that most of the patients eat high-fat meals from the local fast-food restaurant and plans a nutrition workshop. The nurse is applying the nursing process characteristic of:a.organization.b.dynamics.c.adaptability.d.collaboration.
C The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. It is an equally useful method for addressing the needs of a specific population. Decisions regarding which nursing interventions and medical treatments to implement are made on the basis of safety and their effectiveness in meeting a patient's identified needs and desired outcomes. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any setting and at every level of care. The plan of care is individualized for the patient on the basis of assessment findings, changing needs, setting, and timing of interaction, not just outcomes. Following the steps of the nursing process ensures that patient care is well organized and thorough. Collaboration among several members of the health care team is often required to adequately address patient needs. In many cases, nurses incorporate orders from a primary care provider, nursing interventions, and input from others, such as physical therapists, social workers, or respiratory therapists, into a patient's plan of care to help alleviate patient problems and achieve established patient-centered goals and outcomes.
The nursing process is cyclic rather than linear. Because of the cyclic nature, as an individual patient's condition changes:a.The nurse's thought processes do not have to vary.b.Plans of care are easier to use and do not need modification.c.The accuracy and effectiveness of thought processes must be considered.d.Reflective thought is not necessary since issues tend to be repetitive.
C The nursing process is cyclic rather than linear. As an individual patient's condition changes, so does the way a professional nurse thinks about that patient's needs, forcing modification of earlier plans of care. At each step of the nursing process, nurses must consider the accuracy and effectiveness of their thought process. This form of reflective thought is an essential aspect of critical thinking. The evolutionary nature of the nursing process allows nurses to adjust to changing patient needs. Plans of care must evolve as patients' needs change.
The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The essential step that was added in 1991 is:a.assessment.b.diagnosis.c.outcome identification.d.evaluation.
C The term nursing process was first used by Lydia Hall in 1955. In 1973, the American Nurses Association (ANA) identified five specific steps of the nursing process in its Standards of Clinical Practice (1991). These five steps—assessment, diagnosis, planning, implementation, and evaluation—define how professional nursing practice is conducted. Outcome identification was added as an essential aspect of the nursing process by the ANA in 1991. Most nursing professionals and educators recognize outcome identification as part of the planning step of the traditional five-step nursing process.
The nurse makes the following entry on the patient's care plan: "Goal not met. Patient refuses to walk and states, 'I'm afraid of falling.'" The nurse should:a.ignore the patient's concern in evaluating goal attainment.b.document the patient's unwillingness to continue the plan of care.c.continue the plan of care as originally agreed upon.d.modify the care plan in response to the patient's condition and wishes.
D Evaluation focuses on the patient and the patient's response to nursing interventions and goal or outcome attainment. Evaluation is not a record of the care that was implemented. Evaluation must clearly identify the effectiveness of implemented interventions with the patient as its focus. During the evaluation step of the nursing process, nurses use critical thinking to determine whether a patient's short- and long-term goals were met and desired outcomes were achieved. Monitoring whether the patient's goals were attained is a collaborative process involving the patient. Nurses need to ask some questions when evaluating the effectiveness of provided nursing interventions: Did the patient meet the goals and outcome criteria established during the planning phase? Since care began, have new assessment data been identified that should be taken into consideration? Does the care plan need to be modified in response to patient changes? Based on the patient's response to the implemented interventions, should the plan of care be continued, revised, or discontinued?
The charge nurse is discussing a patient's care plan during a team meeting. The team determines that the patient has not met the goal of "ambulating to the nurse's station twice a day" and decides to revise the plan. Which of the following characteristics of the nursing process most represents this decision?a.Organizationb.Dynamicsc.Adaptabilityd.Outcome orientation
D Patient care plans are developed to meet each patient's goals, not the goals of standardized patients or members of the health care team, including the nurse. Decisions regarding which nursing interventions and medical treatments to implement are made on the basis of safety and their effectiveness in meeting a patient's identified needs and desired outcomes. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any setting and at every level of care. The plan of care is individualized for the patient on the basis of assessment findings, changing needs, setting, and timing of interaction, not just outcomes. Following the steps of the nursing process ensures that patient care is well organized and thorough. The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. It is an equally useful method for addressing the needs of a specific population.
The nurse is caring for a patient who will be discharged home following surgical repair of a broken shoulder. The patient tells the nurse, "I don't have anyone at home who can help me cook my meals. Is there something you can do?" Demonstrating the adaptability of the nursing process, the nurse should:a.adjust the patient's care plan so that nursing goals can be met.b.consult the care provider about extending the patient's hospitalization.c.abandon the plan of care as not able to be done.d.contact the social worker about community services.
D The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. It is an equally useful method for addressing the needs of a specific population. Patient care plans are developed to meet each patient's goals, not the goals of standardized patients or members of the health care team, including the nurse. Decisions regarding which nursing interventions and medical treatments to implement are made on the basis of safety and their effectiveness in meeting a patient's identified needs and desired outcomes. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any setting and at every level of care. The plan of care is individualized for the patient on the basis of assessment findings, changing needs, setting, and timing of interaction, not just outcomes. Following the steps of the nursing process ensures that patient care is well organized and thorough.
