CH 16 - Planning

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? A. Client is normotensive. B. Client is drowsy after lunch. C. Client lipids are within range. D. Client reports no headache.

A. Client is normotensive.

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? A. Ongoing B. Discharge C. Initial D. Outcome

A. Ongoing

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care? A. Consult with another nurse. B. Seek research about the disorder. C. Set priorities using client care standards. D. Follow institutional guidelines.

B. Seek research about the disorder.

The nurse recognizes that identifying outcomes/goals must include: A. input from the physician. B. involvement of the client and family. C. input from the multidisciplinary team. D. involvement of the nurse manager and other staff nurses.

B. involvement of the client and family.

Categories of Outcomes

Cognitive: describes increases in patient knowledge or intellectual behaviors Psychomotor: describes patient's achievement of new skills Affective: describes changes in patient values, beliefs, and attitudes

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: A. goal. B. diagnosis. C. evaluation. D. intervention.

D. intervention.

Maslow's Hierarchy of Needs

Physiological needs Safety needs Love and belonging needs Self-esteem needs Self actualization needs

S.M.A.R.T.

Specific, Measurable, Attainable, Realistic, Timely

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? A. "What are your plans after discharge?" B. "Do you want to be discharged without treatment?" C. "Please tell me your thoughts about treating this diagnosis." D. "You need to stop smoking for us to effectively combat this disease."

C. "Please tell me your thoughts about treating this diagnosis."

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. An order set B. Guidelines C. A standardized care plan D. An algorithm

C. A standardized care plan

A client had a cholecystectomy 2 hours previously and is waking up from anesthesia. The client asks, "how long it will be before I can go home?" The nurse responds that most clients are discharged within 2 days. The nurse's answer is most likely based on which piece of information? A. The scientific rationale B. The agency's critical path C. The client outcomes D. The individualized plan of care

B. The agency's critical path

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 'ambulate' represent? A. Conditions B. Verb (action) C. Performance criteria D. Subject

B. Verb (action)

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually A. does not contain abbreviated nursing diagnoses. B. does not contain documented scientific rationales. C. separates goal statements from the plan of care. D. separates outcome criteria from the plan of care.

B. does not contain documented scientific rationales.

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining? A. Structure B. Cost-effectiveness C. Outcome D. Process

C. Outcome

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? A. Individualize the plan to the client. B. Identify the appropriate nursing diagnoses. C. Include the rationale for the interventions. D. Expect to modify the plan significantly.

A. Individualize the plan to the client.

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? A. Answer the client's questions about diet alterations, and then evaluate understanding. B. Start from client's knowledge, teach about diet modifications, and check for learning. C. Present the client with videos and books about diet changes that reduce inflammation. D. Ask the client's learning style, then teach diet information using that style.

B. Start from client's knowledge, teach about diet modifications, and check for learning.

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? A. Coordinating B. Supportive C. Supervisory D. Psychosocial

B. Supportive

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? A. Tell another nurse about this client statement. B. Encourage the client to join a therapy group. C. Add the nursing diagnosis: Risk for Self-Harm. D. Document that the depression has resolved.

C. Add the nursing diagnosis: Risk for Self-Harm.

Which statement correctly describes a nurse-initiated intervention? A. Nurse-initiated interventions are derived from the nursing diagnosis. B. Nurse-initiated interventions are actions performed to diagnose a medical problem. C. Nurse-initiated interventions require a physician's order. D. Nurse-initiated interventions are actions deemed to have a low risk of harm to the client.

A. Nurse-initiated interventions are derived from the nursing diagnosis.

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? A. As soon as possible after the client's surgery B. Once the client has received a discharge order C. Once the client is admitted to the nursing unit from postanesthetic recovery D. On the client's admission to the hospital

D. On the client's admission to the hospital

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? A. Ongoing B. Discharge C. Initial D. Standardized

D. Standardized

Which is an example of a nurse-initiated intervention? A. Administer oxygen at 4 L/min per nasal cannula. B. Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. C. Administer a 1000-mL soap suds enema. D. Teach the client how to splint an abdominal incision when coughing and deep breathing.

D. Teach the client how to splint an abdominal incision when coughing and deep breathing.

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? A. The nurse has omitted the defining characteristics. B. The nurse has not made any error in writing the outcome. C. The outcome should indicate what the nurse will do. D. The nurse has omitted the time frame.

D. The nurse has omitted the time frame.