chap 13

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 standardized care plan

A nurse reviews the client outcomes written by a student nurse. Which outcome requires modification?

By the end of instruction, client will know how to perform dressing changes

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours

The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome

Client will maintain nutritional intake without pain or diarrhea.

A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective?

Client will use chin tuck and double swallow for each bite

A nurse is using the Nursing Outcome Classification system to assist in planning a client's care. The nurse understands that each outcome includes which component? Select all that apply.

Definition Measurement scale Indicators

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing

Discharge planning

A nurse is demonstrating foley catheter care to a client. Which type of nursing intervention does this best represent?

Educational

A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the priority for this client?

Ineffective Impulse Control

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

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 client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?

Ongoing planning

A nurse is caring for a 48-year-old man 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

Outcome evaluation

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

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

For which of the following clients would a standardized plan of care most likely be appropriate?

a client who was admitted for shortness of breath and who has been diagnosed with pneumonia

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's

condition

A nurse is planning care for clients 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 client outcomes selecting evidence-based nursing interventions Communicating the plan of nursing care

A nurse is writing outcomes for clients in a rehabilitation facility. Which guidelines should the nurse consider? Select all that apply.

At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. The nurse should write outcomes that are brief and specific and support the overall plan of care.

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer?

By discharge, client will perform hand hygiene before and after port care.

A nurse administers colchicine according to the standardized plan of care for a client admitted with acute gouty arthritis of the right great toe. Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention?

Client reports diarrhea

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem?

Client will alternate rest periods with exercise throughout the day

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

Identifies factors causing undesirable response and preventing desired change

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client

What are specific measurable and realistic statements of goal attainment?

Outcome criteria

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor

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

Seek research about the disorder

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

Supportive intervention

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 her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?

Upon her admission to the hospital

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family

A nurse is caring for a 30-year-old man status post repair of a left femur fracture. He is currently immobilized and on strict bed rest. The nurse enters the client's room every 2 hours to help him change positions because doing so will help to prevent pressure ulcers. The "help to prevent pressure ulcers" portion of this statement is best described as:

rationale.

The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the best indicator that the outcome expectations have been met

"I walk daily wearing low-heeled shoes."

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 nurse is caring for an overweight, highly stressed 50-year-old male executive who is being discharged from the hospital after undergoing coronary bypass surgery. What is an affective goal for this patient?

By 6/30/15, the patient will reduce the cholesterol in his diet. Reference:

A nurse administers clonidine according to the standardized plan of care for a client admitted with hypertension. Which assessment information deviates from the expected client outcome for the first 24 hours and requires nursing intervention?

Client gains 1 kg (2.2 lb) in 1 day

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?

Client is normal tensive.

Which is an appropriate expected outcome for a client?

Client will ambulate safely with walker in the room within 3 days of physical therapy

The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply

Client will increase nutrition, eating 75% of meals. Client will report pain is controlled at or below 3 of 10. Client will perform dressing change independently.

A nurse is planning nursing interventions for patients on a busy hospital ward. Which guideline would the nurse follow when designing the plan of care?

Date the nursing interventions when written and when the plan of care is reviewed

Which represents appropriate nursing interventions for a client who is on bed rest s/p surgical intervention? Select all that apply.

Deep breathing using an incentive spirometer every hour Change of position every 2 hours

A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking, again." What is the priority nursing diagnosis?

Deficient Diversional Activity

The expected outcome for a client with a new diagnosis of diabetes mellitus 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 is prioritizing the client's nursing diagnoses. Which nursing diagnosis has priority?

Ineffective Airway Clearance related to retention of secretions

After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care

It helps deliver holistic, goal-oriented, individualized care.

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: T: 36.8°C sublingual, HR: 95, RR: 20, BP: 130/65. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. What order is the nurse likely to request first for the client?

Narcotic pain medication to treat pain

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

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention.

The nurse recognizes that an example of a cognitive outcome is

The client identifies three foods high in potassium by August 8.

Which of the following reflects planning? Select all that apply.

The nurse decides to assist the client with ambulation in the hallway twice per shift. The nurse seeks input from the client and family regarding acceptable non-pharmacologic pain management strategies. The nurse considers the developmental level of the client when selecting education materials.

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 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 do this." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm

The nurse is caring for Isabel, a 45-year-old ventilator-dependent quadriplegic. The nurse is in the process of placing IV access when the ventilator alarms occlusion. The nurse assesses Isabel and she appears mildly uncomfortable but is not in acute distress. What is the nurse's priority in the nursing outcome planning?

Assess tracheostomy for patency

Elijah is 9-months-old and admitted to the nurse's unit status post non-accidental trauma. He suffered a left clavicular fracture and fracture of the left femur. He also has a concurrent diagnosis of a stage 2 pressure ulcer. He is alert and oriented to person, place, and time and is taking food and milk by mouth. Which of the following are appropriate outcome criteria for Elijah? Select all that apply.

Elijah will assist with turning every 2 hours. Elijah will feed himself under direct supervision 5 times per day

A client is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes

Family

A nurse is preparing an in-service program for a group of staff nurses who are returning to the workforce. As part of the in-service, the nurse will be describing the different types of client plans of care. Which element would the nurse include as common to any type of plan of care? Select all that apply

Nursing diagnoses Client goals Nursing interventions

A nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The nurse then uses the data to update the client plan of care. What are these actions considered?

Ongoing planning

A nurse is reviewing the plan of care for a client and notes the following: "The client verbalizes three signs of hypoglycemia to the staff accurately before discharge." The nurse interprets this statement as a(n):

Outcome criteria

A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse?

Perform hourly neurovascular assessment.

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention?

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

A 56-year-old woman on the inpatient unit is 2 hours s/p gallbladder surgery. She is just waking up from anesthesia, and asks the nurse how long it will take until she 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?

The agency's critical path

A client is on the surgical unit s/p resection of an intestinal tumor. She is alert and oriented x3. Based on assessment of the client, a medical order to "ambulate with assistance" is written in the chart. This will be the client's first time ambulating. Which best represents a nursing outcome?

The client will ambulate with the assistance of a walker without falling within the next 4 hours

A 63-year-old client in the ICU with a nursing diagnosis of risk for impaired skin integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to her left side she notices that the client has a non-blanching reddened area over her right trochanter. What would be the most appropriate action for the nurse to take?

The nurse repositions the client to her left side and updates the plan of care to turn and reposition the client every hour

A nurse is performing initial care planning for a hospitalized client. Which actions occur during the initial planning of client care? Select all that apply.

The nurse who performs the admission nursing history and physical assessment makes the initial plan. After the initial plan is developed, the nurse prioritizes nursing diagnoses. The nurse identifies client goals and the related nursing care in the initial plan

The nurse is developing a plan of care for a newly admitted client to the nursing unit. The nurse knows that which elements are important to include in this plan of care? Select all that apply.

promoting client participation planning care that is realistic and measurable allowing for involvement of support people

The nurse is writing a measurable outcome for a client with a new prosthesis to begin walking again. Which components must be included in the outcome? Select all that apply

the action the client will perform particular circumstances in which the outcome is to be achieved the client or some part of the client target time when the client is expected to be able to achieve the outcome

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?

to ambulate the client to a bedside chair

A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care?

Include the client and the client's power of attorney in the discussion.

Which nursing diagnosis is the priority

Ineffective breathing patterns

The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?

Mr. Conner will demonstrate proper care of stoma by 3/29/15

A nursing student is writing a care plan for an assigned client to be submitted to the instructor. Before submitting the care plan the student reviews it to ensure that all the necessary components have been addressed. Which component would the student look for? Select all that apply

Nursing diagnoses Client goals Outcome criteria Interventions with rationales Evaluation

A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this client

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse

According to the Nursing Intervention Classification (NIC), the most basic level of nursing intervention is

Physiologic

An older adult female client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease (COPD). Which statement constitutes a long-term outcome

The client will return home able to conduct her activities of daily living (ADLs) without experiencing shortness of breath.

Which of the following is categorized as a psychomotor outcome

Within 2 days of education, the client's wife will demonstrate abdominal dressing change

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority?

Within 48 hours, client will recognize when additional tranquilizers are needed.

A nurse plans a series of muscle strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. Which action by the nurse may have led to failure to meet the outcome?

choosing actions that do not solve the problem

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 ?

developing the plan without client input

A father runs into the emergency room with his 18-month-old son in his arms. The father screams, "Help, he is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?

high priority

A nurse is planning care for a client who has just been diagnosed with type 2 diabetes. Which nursing action is performed during the planning step of the nursing process?

nurse selects nursing measures, including client education

A 5-year-old client was recently diagnosed with type 1 diabetes. The nurse is in charge of her discharge education plan. The nurse knows that site rotation is important for long-term self-care. The statement "will properly identify three areas on her body to inject insulin" represents:

outcome criteria.

The nurse is developing outcomes for the care plan of a client admitted with Parkinson's disease. The nurse will derive the outcomes for this client's care plan from:

the problem statement of the nursing diagnosis