Foundations Chapter 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 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.
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 planning nursing interventions for clients on a busy hospital unit. 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.
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?
Encourage hourly use of the incentive spirometer
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.
Which statement correctly describes a nurse-initiated intervention?
Nurse-initiated interventions are derived from the nursing diagnosis
What are specific measurable and realistic statements of goal attainment?
Outcome criteria
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.
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.
The nurse recognizes that an example of a cognitive outcome is:
The client identifies three foods high in potassium by August 8.
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.
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
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
Which of the following is categorized as a psychomotor outcome?
Within 2 days of education, the client's wife will demonstrate abdominal dressing change.
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
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
discharge planning
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:
intervention
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
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
Psychomotor
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
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."
The nurse understands that which of the following are part of client-centered outcomes? Select all that apply.
-The outcome demonstrates resolution of the nursing problem. -Long-term outcomes may be used as discharge goals. -Expected client outcomes are used to evaluate achievement. -Goals and outcomes are interchangeable.
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.
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?
updating the diet orders in the client's plan of care
