Chapter 16

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. It creates a teaching log for family. It provides the client with information about treatments. It verifies staffing.

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

The nurse, in collaboration with the client's family, is assigning priorities related to the care of the client. The nurse explains that when setting priorities it is important to look at the urgency of specific problems. What provides the best framework for prioritizing client problems? Maslow's hierarchy of needs Availability of hospital resources Nursing skill Family member statements

Maslow's hierarchy of needs

The nurse is caring for a 48-year-old male client with a new colostomy. Which client goal for Mr. Conner is written correctly? Mr. Conner will be able to care for stoma and cope with psychological loss by 29MAR2015 Mr. Conner will know how to care for his stoma by 29MAR2015. Mr. Conner will demonstrate proper care of stoma by 29MAR2015. Explain to Mr. Conner the proper care of the stoma by 29MAR2015.

Mr. Conner will demonstrate proper care of stoma by 29MAR2015.

A nurse is formulating a nursing plan of care for a client based on assessment data. When writing this plan, which would be most important for the nurse to include? Client outcomes Outcome criteria Nursing interventions Evaluation

Nursing interventions

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? Initial planning Discharge planning Ongoing planning Outcome planning

Ongoing planning

A nurse is reviewing the plan of care for a client and notes : "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." How does the nurse interpret this statement? Nursing Diagnosis Intervention Outcome criteria Evaluation

Outcome criteria

What are specific measurable and realistic statements of goal attainment? Nursing diagnoses Outcome criteria Nursing interventions Evaluation

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. Elevate the injured arm on a pillow. Apply ice to the casted extremity. Give prescribed pain meds.

Perform hourly neurovascular assessment.

According to the Nursing Intervention Classification (NIC), the most basic level of nursing intervention is: Physiologic Coping Family Behavioral

Physiologic

The nurse recognizes that an example of a cognitive outcome is: The client accurately measures the radial pulse for 1 minute by February 2. The client identifies three foods high in potassium by August 8. The client verbalizes increased confidence in testing glucose levels. The client demonstrates self-catheterization using clean technique by June 3.

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

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: a critical pathway. a guideline. an algorithm. an order set.

a guideline.

A nurse is reviewing the outcome criteria that were developed for a client. The nurse determines that the criteria are appropriate because which characteristic is met? Select all that apply. can be measured must be broad in scope are specific are focused short-term are realistic

can be measured are realistic are specific

Which statement on a plan of care would a nurse identify as a nursing intervention? readiness for enhanced communication performs range of motion exercises to all joints each morning administers insulin correctly demonstrates deep-breathing exercises after education

performs range of motion exercises to all joints each morning A nursing intervention is a treatment performed to enhance client outcomes, such as "performs range of motion exercises to all joints each morning." "Administers insulin correctly is a goal statement. "Demonstrates deep-breathing exercises after education" is a client outcome criteria. Readiness for enhanced communication is a wellness nursing diagnosis.

A nurse identifies outcomes of care for the hospitalized, postoperative client primarily to: focus on health promotion. document nursing practice. evaluate nursing interventions. provide individualized care.

provide individualized care.

A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest and assistance with position change is provided every 2 hours to prevent pressure ulcers. What is the portion of "assistance to prevent pressure ulcers" portion of this statement described as? nursing diagnosis. nursing intervention. rationale. outcome criteria.

rationale.

A nurse writes down the following outcome for a depressed client: "By 6/9/12, the client will state three positive benefits of receiving counseling." This is an example of which type of outcome? Psychomotor Affective Realistic Cognitive

Affective

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? Interrupted Breastfeeding Ineffective Thermoregulation Impaired Parenting Altered Gas Exchange

Altered Gas Exchange

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 walking gait is steady BP is lower than admission No reports of pain or headache Client gains 1 kg (2.2 lb) in 1 day

Client gains 1 kg (2.2 lb) in 1 day

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 use oxygen by nasal cannula when short of breath. Client will alternate rest periods with exercise throughout the day. Client will consistently perform pulmonary exercises. Client will increase protein intake in small frequent meals.

Client will alternate rest periods with exercise throughout the day.

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 Activity Intolerance Disturbed Body Image Impaired Walking

Deficient Diversional Activity

A nurse is working with a newly admitted client with diabetes to develop client outcomes. When writing these outcomes, which verb would be appropriate to use in the statement. Select all that apply. Understand Demonstrate Know State Explain

Demonstrate State Explain

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. Call respiratory therapy for help. Continue to place IV. Ask Isabel to cough and clear her tracheostomy tube.

Assess tracheostomy for patency. Airway impairment is considered a life-threatening emergency. This must be assessed and resolved before proceeding with other task

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 receive influenza vaccine. Client will report pain is controlled at or below 3 of 10. Client will increase nutrition, eating 75% of meals. Client will maintain oxygen saturation at 81%. Client will perform dressing change independently.

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.

Which of the following outcomes is sufficiently measurable? "Client will progress from clear fluid diet to full fluid diet without experiencing nausea." "Increase client's diet from clear fluids to full fluids by 12/15/2016." Client will tolerate a full fluid diet with no reports of nausea by 12/15/2016." "Client will maintain adequate intake with no reports of nausea by 12/15/2016."

Client will tolerate a full fluid diet with no reports of nausea by 12/15/2016."

Which intervention performed by the nurse is most appropriate for assisting a client in meeting physiologic needs based on Maslow's Hierarchy of Needs? Providing the mother the phone number for the Poison Control Center Seeking input from the client regarding their preferences for a snack Cutting up food and opening drink containers for the client Assisting the client to validate their feelings regarding treatment options

Cutting up food and opening drink containers for the client

The nurse is writing outcomes that are measurable for a client. What verbs will the nurse use in order to write these outcomes?Select all that apply. Verbalize Know Hear Define Feel

Define Verbalize

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? Reassess in 4 hours and document the findings. Provide oral pain medication before ambulation. Encourage hourly use of the incentive spirometer. Promote oral fluid intake between meals.

Encourage hourly use of the incentive spirometer.

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? Uric acid level decreases. Client reports diarrhea. Foot remains red and swollen. Client walks to the bathroom.

Foot remains red and swollen. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for gouty arthritis is reduction in pain. Pain reduction may occur before reduction of redness and swelling is visible. Diarrhea is a possible toxic effect of colchicine.

Which action is included in the planning process when a nurse is caring for an older adult client with AIDS? Analyze the client's response to medicines. Assess the client's overall health. Identify the client's health-related problems. Identify measurable goals or outcomes.

Identify measurable goals or outcomes.

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

Nurse-initiated interventions are derived from the nursing diagnosis.

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. Offer to help the client walk the length of the hallway each day. The client will become mobile within a 24-hour period. The nurse will help the client ambulate the length of the hallway once a day.

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. "Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse" has all of these characteristics. "The nurse will help the client ambulate the length of the hallway once a day" is not specific in whether assistance is required and it is not timebound. "Offer to help the client walk the length of the hallway each day" is a nursing intervention. "The client will become mobile within a 24-hour period" is not specific or measurable.

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? Prepare the client for surgery. Provide preoperative education. Evaluate the need for antibiotics. Resolve the client's anxiety.

Resolve the client's anxiety.

A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement? Ask the client to describe a personal walking goal. Return the client to bed and provide pain relief measures. Adjust expected outcome to have client ambulate a shorter distance. Review evidence-based interventions for the client's pain.

Return the client to bed and provide pain relief measures.

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

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

Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal? Arrange for the social worker to schedule home health care with discharge planning. Tell the client's family to bring in clothes a size larger to make dressing easier. Assist the client to put on the clothing that goes over the operated leg. Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.

Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.

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? The scientific rationale The client outcomes The agency's critical path The individualized plan of care

The agency's critical path The critical path is based on large bodies of research and provides information on the expected course of a client's treatment or illness. Deviations from the critical path are documented in the individualized plan of care.

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 sometime today. Physical therapy will be consulted to assist the client with ambulation. The client will ambulate with the assistance of a walker without falling within the next 4 hours. The client will ambulate to the restroom 3 times this shift.

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

The nurse is planning the care of a client. What behaviors reflect planning?Select all that apply. The nurse assesses the client's usual sleep routine. The nurse assists the client with bathing, grooming, and dressing. 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 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.

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2015." Why is this outcome inadequate? The outcome is not related to an independent nursing action. The outcome is not observable or measurable. The statement expresses a client outcome as a nursing intervention. The outcome does not specify the conditions in which it will be achieved.

The outcome is not observable or measurable.

Which of the following is categorized as a psychomotor outcome? The client's skin will remain smooth, moist, and without breakdown or ulceration. Within 2 days of education, the client's wife will demonstrate abdominal dressing change. The client will verbalize understanding of need to continue to take medications as prescribed. Within one week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day.

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

The nurse assigned to care for a client has established client outcomes and outcome criteria. After completing this task, what would the nurse do next? Write a client plan of care Identify objectives. Determine client goals. Establish priorities

Write a client plan of care

The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is: an order set. a clinical pathway. a protocol. an algorithm.

a clinical pathway.

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client and family's ability to cope. What action should the nurse take with this client? providing more information about diabetes comforting the client and family testing the client's glucose levels asking the client if anyone in the family also has diabetes

comforting the client and family

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? failing to update the written plan of care choosing actions that do not solve the problem beginning the plan without family to help developing the plan without client input

developing the plan without client input

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: does not contain documented scientific rationales. does not contain abbreviated nursing diagnoses. separates outcome criteria from the plan of care. separates goal statements from the plan of care.

does not contain documented scientific rationales.

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. collecting and interpreting client data identifying expected client outcomes selecting evidence-based nursing interventions recording client outcomes establishing priorities Communicating the plan of nursing care

establishing priorities identifying expected client outcomes selecting evidence-based nursing interventions Communicating the plan of nursing care

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

intervention.

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

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

The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) 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 take my medications on an empty stomach for maximum effect." "I should call my health care provider if I have a sore that won't heal." "I should increase water intake if I have dark bowel movements." "I will take the medications until the inflammation goes away."

"I should call my health care provider if I have a sore that won't heal."

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 take extra calcium to make my bones stronger." "I walk daily wearing low-heeled shoes." "I turn on lights at night so I won't fall." "I removed scatter rugs from my home."

"I walk daily wearing low-heeled shoes." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new diagnosis must learn appropriate actions for care. With osteoporosis the most important means to prevent further bone loss is weight-bearing activity, such as walking. While each option is appropriate for a client with osteoporosis, only one includes both components of the outcome. Activities that prevent falls, such as wearing low-heeled tie shoes, turning on lights, and removing scatter rugs, are important for safety.

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 take my medications between meals for maximum effect." "I will test my glucose level before meals and use sliding scale insulin." "I will take insulin until my blood sugar levels are normal." "I will mix insulin glargine with insulin lispro at bedtime."

"I will test my glucose level before meals and use sliding scale insulin."

The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate? "Nursing interventions are pretty much the same for clients that have the same medical diagnosis." "Nursing interventions should be consistent with standards of nursing care and research findings." "Nursing interventions are selected based on the etiology in the nursing diagnosis and must be compatible with other therapies planned for the client." "The client's developmental level, values, beliefs, and cultural and psychosocial background should be considered when selecting nursing interventions."

"Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care? A 45-year-old man with burns to his upper arms and chest and soot on his face who is restless and anxious A 68-year-old woman with bruises across her chest and lower abdomen who is observed rubbing the bruised area on her lower abdomen and moaning An 18-year-old woman sitting up in bed with an egg-size hematoma and a 5 cm laceration on her forehead who is talking rapidly on her cell phone A 4-year-old with a deformed left lower leg with equal pedal pulses in both feet and who is crying loudly

A 45-year-old man with burns to his upper arms and chest and soot on his face who is restless and anxious Burns to the chest and soot on the client's face indicate that the client inhaled hot smoke and is at risk for ineffective airway clearance due to possible tracheal/bronchial edema. Restlessness and anxiety can indicate hypoxia and are characteristics of the nursing diagnoses of impaired gas exchange and acute confusion. This client should receive the highest priority of care (airway), should be assessed for stridor and respiratory distress, and the oxygen saturation should be monitored.

A committee of nurses on a hospital unit is developing a clinical pathway for a high-risk group of clients. This pathway will include steps for assessment and interventions in which there will be no flexibility for the nursing staff. What is this structured care methodology called? An algorithm National guidelines Clinical practice guideline Concept map

An algorithm Efforts to standardize nursing care have taken different forms, including procedures (1960s), standards of care (1970s), algorithms (1980s), and clinical practice guidelines (1990s). Each of these aims to help the nurse identify and select interventions that produce optimal care, reduce legal risks, and lower health care costs. An algorithm is useful in the management of high-risk groups. It includes steps in the assessment and interventions the nurses will use. There is no provider flexibility. A concept map is a flexible tool used to plan care.

A nurse is caring for a client with a bowel obstruction that has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply. Auscultate for bowel sounds. Allow the client to order favorite foods from the hospital menu. Consult with dietitian regarding appropriate foods. Begin feedings with clear broth.

Auscultate for bowel sounds. Begin feedings with clear broth. Consult with dietitian regarding appropriate foods.

The nurse is writing care plans for clients in the team. Which is an appropriate expected outcome for a client? After attending diabetic education classes, client will understand diet modifications. Client will independently follow transplant medication schedule 1 week after surgery. Client will perform complete PICC line care within 24 hours of insertion. By the next clinic visit, client will report taking antidepressant medication.

Client will independently follow transplant medication schedule 1 week after surgery.

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 learn to cook foods that meet personal nutritional needs. Client will talk with campus cafeteria manager about identifying safe meals. Client will maintain nutritional intake without pain or diarrhea. Client will understand what inflammatory bowel disease is

Client will maintain nutritional intake without pain or diarrhea.

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem? Client will not leave the premises without a caregiver. Client will identify landmarks that indicate location of home. Client will wear an ID bracelet with name and contact information. Client will consistently return to the police station when lost.

Client will not leave the premises without a caregiver.

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? Ask the client what the priority needs are Hold a unit meeting to determine needs. Include the client and the client's power of attorney in the discussion. Consult the oncology nurse specialist in order to determine priorities.

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

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 highest priority for this client? Ineffective Impulse Control Insomnia Fatigue Agitated Movement

Ineffective Impulse Control p. 230 Rationale: Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, or circulation; or safety issues such as threats of self-harm. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences (such as physical or emotional impairment). The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. In this case, the lack of impulse control is the greatest risk to the client's well-being.

The nurse is developing a plan of care for a client. When planning care in the outcome identification phase, what does the nurse determine is the benefit of this phase? It promotes the client being an active participant in care It allows the nurse to evaluation the outcomes It promotes an effective diagnostic process It allows for the identification of proper diagnoses.

It promotes the client being an active participant in care

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. Past medical history Nursing diagnoses Medical diagnoses Nursing interventions Client goals

Nursing diagnoses Client goals Nursing interventions

A nurse is applying the nursing process and is involved in establishing priorities. The nurse is most likely in which phase of the nursing process? Diagnosis Assessment Outcome identification and planning Implementation

Outcome identification and planning

Which of the following is a correctly written nursing intervention? Select all that apply. Understand the side effects of furosemide. Provide opportunities for the client to express concerns and verbalize feelings. Reposition the client from side to side every hour around the clock. Provide 5 to 6 small meals daily. Know the signs and symptoms of infection.

Provide 5 to 6 small meals daily. Reposition the client from side to side every hour around the clock. Provide opportunities for the client to express concerns and verbalize feelings.

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. Which goal written by the nurse requires revision? By 08/02/2018, the client will state 3 therapeutic methods of reducing stress. The client will understand the effects of smoking related to heart disease. By 8/02/18, the client will state when to notify the health care provider after discharge. By 8/02/18, the client will demonstrate a daily meal plan to reduce cholesterol in the diet.

The client will understand the effects of smoking related to heart disease.

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 nonblanching, 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 back and documents the condition of the client's skin in the medical record. The nurse repositions the client to her back and documents the intervention in the client's record. The nurse repositions the client to her left side and updates the plan of care to turn and reposition the client every hour. The nurse repositions the client to her left side and plans to return in 2 hours to reassess the reddened area on the client's right trochanter.

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 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? The nurse identifies client strengths and weaknesses. The nurse selects nursing measures, including client education. The nurse interprets and analyzes the client data. The nurse establishes a database for the client.

The nurse selects nursing measures, including client education.

When creating a care plan, which is the purpose of identifying the client outcome? To design a plan of care to address the health problem To evaluate the plan of care developed To coordinate the nursing intervention To provide a basis for the scientific rationale

To design a plan of care to address the health problem The primary purpose of the outcome identification and planning step of the nursing process is to design a plan of care with and for the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes.

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 a client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident a client whose increasing fatigue in recent days has not yet been attributed to a specific health problem a client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy.

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

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? stating outcomes too broadly choosing actions that do not solve the problem beginning the plan without family to help failing to update the written plan of care

choosing actions that do not solve the problem Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. In this case, ALS is a progressive degenerative neuromuscular disorder. It is unrealistic to expect the client to regain abilities that are lost.

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 description in subjective terms of the expected client behavior modifiers describing the end result target time when the client is expected to be able to achieve the outcome the client or some part of the client particular circumstances in which the outcome is to be achieved

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

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: assessment data gleaned from the physician's progress notes. the defining characteristics in the nursing diagnosis statement. the problem statement of the nursing diagnosis. assessment data provided by the multidisciplinary team.

the problem statement of the nursing diagnosis.

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client? to help the client return to activities of daily life to maintain a healthy and active lifestyle to prevent repeat surgery in the client to ambulate the client to a bedside chair

to ambulate the client to a bedside chair

A client is required to be n.p.o. 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? obtaining written consent for the diagnostic procedure posting the sign "n.p.o. after midnight" over the bed adding the diagnosis "altered nutrition, less than required" updating the diet orders in the client's plan of care

updating the diet orders in the client's plan of care

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority? By day 2 of admission the client will remain safe and without injury from withdrawal symptoms Client will discuss drinking habits in therapy sessions the day after admission. Within 3 days, client will be discharged. Client will commit to completing a 12-step program within 24 hours of admission.

By day 2 of admission the client will remain safe and without injury from withdrawal symptoms

The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. Which outcome statement is structured correctly? Client will understand the importance of follow-up laparoscopic examination. By the next clinic visit, the nurse will discuss the client's feelings around infertility. By discharge from the fertility clinic, the client will achieve full-term pregnancy. After visiting the clinic, client will indicate a desire for adoption.

By discharge from the fertility clinic, the client will achieve full-term pregnancy.

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer? Client will schedule radiation therapy sessions and plan for chemotherapy. After attending cancer support group, client will state her mood is good. By discharge, client will perform hand hygiene before and after port care. By the next clinic visit, client will report needing antiemetic medication.

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

A nurse reviews the client outcomes written by a student nurse. Which outcome requires modification? Client will demonstrate safe transfers from bed to chair within 24 hours. Client will correctly self-administer subcutaneous insulin before discharge. By the end of instruction, client will know how to perform dressing changes. Within 2 days, client will describe two responses to firing of the internal defibrillator.

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

A nursing student is writing a student care plan for an assigned client. When identifying specific interventions to be used, which aspect would the student need to include with the interventions? Nursing orders Goals Outcome criteria Scientific rationales

Scientific rationales

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 avoid straws and drink thickened liquids. Client will chew food well and use a tongue sweep. Client will use chin tuck and double swallow for each bite. Client will sit in chair for all meals and snacks.

Client will use chin tuck and double swallow for each bite.

When establishing client outcomes with the client, what is the qualifier in the outcome? The problem statement The short-term goal The long-term goal The outcome parameter

The outcome parameter