Ch 15, 16, 17
The nurse is selecting interventions after gathering and analyzing client data. Interventions that the nurse includes will meet what criterion?
Aligned with a goal Explanation: Nursing interventions must be specifically designed to meet the identified goal. These are grounded in the scope of nursing practice so they may not require collaboration with other disciplines. Goals and outcomes should be time-specific but interventions may not always be.
Which guideline should the nurse follow when including interventions in a plan of care?
Date the nursing interventions when written and when the plan of care is reviewed. Explanation: Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The health care provider does not approve and sign the interventions, because they are nursing interventions.
A nurse is caring for a toddler who has been treated on two different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment. What is an appropriate nursing diagnosis for this client? You Selected: Child Abuse related to unsafe home environment Correct response: High Risk for Injury related to unsafe home environment
Explanation: The nursing diagnosis "High Risk for Injury related to unsafe home environment" is appropriate because it contains the NANDA-I nursing diagnosis problem statement and the etiology of the problem. High Risk for Injury related to abusive parents is accusatory and may not be accurate. High Risk for Injury related to impaired home management does not accurately identify the etiology of the problem. Child Abuse is not a NANDA-I approved nursing diagnosis.
When a nurse documents an intervention involving a one-person assist of a client to the chair, which type of nursing intervention does this represent?
Psychomotor interventions include activities such as positioning, inserting, and applying. A psychosocial intervention focuses on supporting, exploring, and encouraging. Maintenance and surveillance are monitoring interventions.
When developing nursing diagnoses, the nurse should focus on which area? Correct response: Human responses to actual or potential health problems
The main focus of nursing diagnoses is on monitoring human responses to actual or potential health problems, whereas the main focus of medical diagnoses and collaborative problems is on monitoring the pathophysiological responses of body organs or systems. Actions to be initiated for treatment are the main focus for interventions or treatment. Collaboration with the health care provider to validate the problem reflects medical diagnoses or collaborative problems.
A nurse is educating a client about care to be taken in nephrotic syndrome. The client expresses that the education is of no use because the disease is not curable. What nursing diagnosis should the nurse formulate with regard to the client's concern?
The most appropriate nursing diagnosis for the client is the Risk for Powerlessness. The client feels that the disease is not under the client's control and any personal efforts will not affect the outcome. Disturbed Body Image is not an appropriate answer because the client does not seem to be concerned about the appearance of the body. Impaired Comfort is also not an appropriate nursing diagnosis because the client does not demonstrate any sign of discomfort. There is not enough indication that the client is at risk for suicide.
