Fundamentals Chapter 16

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? A plan derived from a consensus of opinions of all staff members A plan designed to support the client physically A plan with problems that are easily solved A plan made in conjunction with the hospital's ethics committee

B

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? Discharge Initial Ongoing Outcome

C

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

C

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 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? An algorithm Guidelines An order set A standardized care plan

D

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. Promote oral fluid intake between meals. Provide oral pain medication before ambulation. Encourage hourly use of the incentive spirometer.

D

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? Maintenance Surveillance Supervisory Educational

D

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

D

Structured Care Methodologies

Procedure: set of how-to action steps Standard of care: description of acceptable level of patient care Algorithm: set of steps used to make a decision Clinical practice guideline: statement outlining appropriate practice for clinical condition or procedure

SMART goals

goals that are specific, measurable, attainable, realistic, and timely

Types of planning

initial, ongoing, discharge

discharge planning

should begin when client is admitted

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. The nurse will help the client ambulate the length of the hallway once a day. Offer to help the client walk the length of the hallway each day. The client will become mobile within a 24-hour period.

A

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: discharge planning. initial planning. comprehensive planning. ongoing planning.

A

Which action should the nurse perform during the planning step of the nursing process? Selects nursing measures, including client education Interprets and analyzes the client data Establishes a database for the client Identifies client strengths and weaknesses

A

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

B

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? Structure Outcome Cost-effectiveness Process

B

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? Supervisory Supportive Coordinating Psychosocial

B

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 the portion in italics represent? Conditions Verb (action) Subject Performance criteria

B

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 mix insulin glargine with insulin lispro at bedtime." "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 take my medications between meals for maximum effect."

B

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? 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. Present the client with videos and books about diet changes that reduce inflammation. Ask the client's learning style, then teach diet information using that style.

B

What are specific measurable and realistic statements of goal attainment? Evaluations Outcomes Nursing diagnoses Nursing interventions

B

Which guideline should the nurse follow when including interventions in a plan of care? Make sure the nursing interventions are unrelated to the original outcomes. Date the nursing interventions when written and when the plan of care is reviewed. Make sure the attending physician approves of and signs the nursing interventions. Make sure each nursing intervention does not describe the action the nurse should perform.

B

Which is an appropriate expected outcome for a client? A)After attending sibling classes, client will be happy about a new baby and demonstrate feeding. B)Client will ambulate safely with walker in the room within 3 days of physical therapy. C)Client will perform complete ostomy care while bathing on the second postoperative day. D)By the next clinic visit, client will report taking antihypertensive medication.

B

Which statement correctly describes a nurse-initiated intervention? Nurse-initiated interventions require a physician's order. Nurse-initiated interventions are derived from the nursing diagnosis. 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.

B

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? "Client will learn to cope more effectively." "Client will list positive coping strategies and use them." "Client will identify one coping strategy to try by end of week." "Client tries using relaxation as a means to cope."

C

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? Set priorities using client care standards. Follow institutional guidelines. Seek research about the disorder. Consult with another nurse.

C

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? "Client will list positive coping strategies and use them." "Client tries using relaxation as a means to cope." "Client will learn to cope more effectively." "Client will identify one coping strategy to try by end of week."

D

The nurse is developing goals for a newly admitted client with visual and auditory hallucinations. Which outcome is the priority for the client? Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior. Client will understand that the hallucinations aren't real in therapy sessions before discharge. Within 2 days, client will perform personal hygiene without reminders. Client will verbalize side effects of antipsychotic medications within 24 hours.

A

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: identifies client strengths. suggests client goals to promote desired change. identifies the unhealthy response preventing desired change. identifies factors causing undesirable response and preventing desired change.

D

initial planning

Developed by the nurse who performs the nursing history and physical assessment Addresses each problem listed in the prioritized nursing diagnoses Identifies appropriate patient goals and related nursing care

Goal of Outcome Identification and Planning Step

Establish priorities Identify and write expected patient outcomes Select evidence-based nursing interventions Communicate the plan of care

Types of Nursing Interventions

nurse initiated physician initiated collaborative

ongoing planning

planning carried out by any nurse who interacts with the patient to keep the plan up to date, to facilitate the resolution of health problems, to manage risk factors, and to promote function

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

A

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? Nurses are responsible for reminding physicians to implement orders. Nurses do carry out interventions in response to a physician's order. Nurses do not carry out physician-initiated interventions. Nurses are not legally responsible for these interventions.

B

A client in the intensive care unit 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 the client's left side, the nurse notices that the client has a nonblanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take? A)The nurse repositions the client to the left side and plans to return in 2 hours to reassess the reddened area on the client's right trochanter. B)The nurse repositions the client to the client's back and documents the condition of the client's skin in the medical record. C)The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour. D)The nurse repositions the client to the client's back and documents the intervention in the client's record.

C

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? Review evidence-based interventions for the client's pain. Adjust expected outcome to have client ambulate a shorter distance. Return the client to bed and provide pain relief measures. Ask the client to describe a personal walking goal.

C

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? Client will maintain adequate hydration within 2 days. Client will eat small meals of bland foods for 3 days. Client will have formed stools within 24 hours. Client will identify the food that caused the condition within 3 hours.

C

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? As soon as possible after the client's surgery Once the client is admitted to the nursing unit from postanesthetic recovery On the client's admission to the hospital Once the client has received a discharge order

C

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 reports no headache. Client is drowsy after lunch. Client is normotensive. Client lipids are within range.

C

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

C

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

D

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: support system. past medical history. medical orders. condition.

D

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 08/02/18, the client will state three therapeutic methods of reducing stress. 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.

D

Maslow's Hierarchy of Needs

physiological, safety, love/belonging, esteem, self-actualization