GERO.....Chapter 4: The Use of the Nursing Process and Nursing Diagnosis in the Care of Older Adults

Which best describes goals? 1) Resident-focused 2) Nurses providing ordered care 3) Priorities of the nursing facility 4) Priorities set by the physician's orders

1) Resident-focused

15. The nurse is evaluating care provided to an older patient. What is the purpose of the evaluation phase of the nursing process? Select all that apply. 1. Determine if goals are met. 2. Assess the outcomes of care. 3. Make the next day's assignments. 4. Ensure the resident is charged for all care. 5. Validate information to bill the insurance company.

. Determine if goals are met. 2. Assess the outcomes of care.

13. The nurse is preparing to plan care for a newly admitted resident. What should be included during the planning phase of the nursing process? Select all that apply. 1. Setting priorities 2. Identifying goals 3. Designing interventions 4. Evaluating outcomes of care 5. Identifying outcomes of care

. Setting priorities 2. Identifying goals 3. Designing interventions 5. Identifying outcomes of care

Which statement defines the nursing process? 1) A problem-solving approach 2) A standardized care-planning method 3) An intuitive approach to planning nursing care 4) A structured and inflexible way to approach problems

1) A problem-solving approach..

What is embedded within the MDS responses? 1) Care area triggers 2) Care area assessment 3) Resident assessment protocols 4) Resident assessment instrument

1) Care area triggers

What is the purpose of the evaluation phase of the nursing process? Select all that apply. 1) Determine if goals are met. 2) Assess the outcomes of care. 3) Make the next day's assignments. 4) Ensure the resident is charged for all care. 5) Validate information to bill the insurance company.

1) Determine if goals are met. 2) Assess the outcomes of care.

Which are care area triggers? Select all that apply. 1) Falls 2) Delirium 3) Activities 4) Dental care 5) Arrhythmia

1) Falls 2) Delirium 3) Activities 4) Dental care

What is included in the resident assessment instrument (RAI)? Select all that apply. 1) Minimum data set (MDS) 2) Care area assessment (CAA) 3) Medication reconciliation form 4) Medicare and Medicaid conditions of participation 5) RAI utilization guidelines

1) Minimum data set (MDS) 2) Care area assessment (CAA) 5) RAI utilization guidelines

What is included in an admission assessment? Select all that apply. 1) Nursing history 2) Physical examination 3) Interview with the resident 4) Review of laboratory values 5) Previous facility nurse's notes

1) Nursing history 2) Physical examination 3) Interview with the resident 4) Review of laboratory values

Based on Maslow's hierarchy of needs, which represents the most appropriate list of priorities? 1) Nutrition less than body requirements; constipation; self-care deficit; confusion 2) Constipation; self-care deficit; confusion; nutrition less than body requirements 3) Nutrition less than body requirements; self-care deficit; confusion, constipation 4) Self-care deficit; confusion; constipation; nutrition less than body requirements

1) Nutrition less than body requirements; constipation; self-care deficit; confusion

What is included in the nursing plan of care? Select all that apply. 1) Problems 2) Goals to be achieved 3) Time the action is to occur 4) Actions to address problems 5) Person to address the actions

1) Problems 2) Goals to be achieved 4) Actions to address problems 5) Person to address the actions

Why is it important for all disciplines to participate in the planning of a resident's care? 1) Reduces duplication of effort 2) Ensures that everyone is working 3) Speeds up the process of providing care 4) Ensures enough time to document at the end of the shift

1) Reduces duplication of effort

Why is a written plan of care created for all residents of a nursing facility? Select all that apply. 1) Required by federal regulations 2) Required by states for nursing licensure 3) Required by standards of nursing practice 4) Required by the nursing home administrator 5) Required by continuing education organizations

1) Required by federal regulations 3) Required by standards of nursing practice

The nurse provides a resident with medication to aid with constipation. What should be included when documenting this intervention? 1) Resident's response 2) Number of pills remaining 3) Number of residents needing the medication 4) Resident's location when the medication was given

1) Resident's response

What is included in the planning phase of the nursing process? Select all that apply. 1) Setting priorities 2) Identifying goals 3) Designing interventions 4) Evaluating outcomes of care 5) Identifying outcomes of care

1) Setting priorities 2) Identifying goals 3) Designing interventions 5) Identifying outcomes of care

Which health-care provider implements the resident care plan? 1) The entire nursing team 2) The registered nurse (RN) 3) The licensed practical nurse (LPN) and the certified nursing assistant (CNA) 4) The RN and the CNA

1) The entire nursing team

Which is an appropriate goal for a resident who has a history of falling? 1) The resident will have no falls in the next 90 days. 2) The resident will be toileted q2h for the next week to prevent falls. 3) The resident will be walked by the physical therapy assistant two times a day. 4) The resident will be assessed for complaints of dizziness or unsteadiness for the next 90 days.

1) The resident will have no falls in the next 90 days.

12. The nurse is assessing a new resident. What should the nurse include when using the resident assessment instrument (RAI)? Select all that apply. 1. Minimum data set (MDS) 2. RAI utilization guidelines 3. Care area assessment (CAA) 4. Medication reconciliation form 5. Medicare and Medicaid conditions of participation

1. Minimum data set (MDS) 2. RAI utilization guidelines 3. Care area assessment (CAA)

11. The nurse is completing an admission assessment. What information should be included? Select all that apply. 1. Nursing history 2. Physical examination 3. Interview with the resident 4. Review of laboratory values 5. Previous facility nurse's notes

1. Nursing history 2. Physical examination 3. Interview with the resident 4. Review of laboratory values

14. The nurse is preparing a plan of care for an older patient. What should be included in the plan? Select all that apply. 1. Problems 2. Goals to be achieved 3. Time the action is to occur 4. Actions to address problems 5. Person to address the actions

1. Problems 2. Goals to be achieved 4. Actions to address problems 5. Person to address the actions

10. The nurse provides a resident with medication to aid with constipation. What should be included when documenting this intervention? 1. Resident's response 2. Number of pills remaining 3. Number of residents needing the medication 4. Resident's location when the medication was given

1. Resident's response

Which statement best describes the nursing process? 1) A step-by-step linear plan 2) A step-by-step circular plan 3) A standardized plan of care for specific diseases or disorders 4) A plan of care designed by the physician according to the medical diagnosis

2) A step-by-step circular plan

Which actions facilitate that a resident's plan of care will be followed by CNAs? Select all that apply. 1) Assigning CNAs to pass linen 2) Giving the CNAs written assignments 3) Scheduling CNAs to do the same tasks 4) Discussing the plan of care with the CNAs 5) Using primary CNAs with steady assignments

2) Giving the CNAs written assignments 4) Discussing the plan of care with the CNAs 5) Using primary CNAs with steady assignments

Which statement describes the process of identifying a nursing diagnosis? 1) Setting goals for nursing care 2) Identifying the patient's strengths and weaknesses 3) Reviewing medical-surgical nursing texts for patterns of disease processes 4) Selecting a nursing diagnosis from a list approved by the North American Nursing Diagnosis Association (NANDA)

2) Identifying the patient's strengths and weaknesses

Why should CNAs help in the development of nursing interventions for a resident's plan of care? 1) They are nicer to the resident. 2) They spend the most time with the resident. 3) They have the most theory-based knowledge. 4) They are better received by the family members.

2) They spend the most time with the resident.

5. The nurse is asked to explain the nursing process. In which way should the nurse describe this process? 1. A step-by-step linear plan 2. A problem-solving process 3. A standardized plan of care for specific diseases or disorders 4. A plan of care designed by the physician according to the medical diagnosis

2. A problem-solving process

8. The nurse is identifying interventions for an older patient's plan of care. Why should the nurse ask the certified nursing assistants (CNAs) to help develop these interventions? 1. They are nicer to the resident. 2. They spend the most time with the resident. 3. They have the most theory-based knowledge. 4. They are better received by the family members.

2. They spend the most time with the resident.

In which step of the nursing process does the nurse complete the minimum data set (MDS)? 1) Planning 2) Diagnosis 3) Assessment 4) Physician orders

3) Assessment

What should the nurse consult when documenting care provided to a resident in a nursing facility? 1) Physician's progress note 2) Medical-surgical textbook 3) CNAs' flow sheet information 4) Medication administration record

3) CNAs' flow sheet information

The nurse is reviewing information received from an acute care facility for a patient being transferred to the nursing home. What information should the nurse expect regarding the patient's functional ability? Select all that apply. 1) Need for oxygen 2) Integrity of the skin 3) How the patient bathes 4) Assistance needed to eat 5) How the patient transfers

3) How the patient bathes 4) Assistance needed to eat 5) How the patient transfers

What should be done with the plan of care for a resident who is discharged back home? 1) Discard it. 2) Provide a copy to the family. 3) Keep it with the medical record. 4) Send it to the resident's physician.

3) Keep it with the medical record.

Which is NOT a step in the nursing process? 1) Planning 2) Assessment 3) Physician orders 4) Nursing diagnosis

3) Physician orders

After the care plan is completed on a new admission what must be done? 1) Notify the physician so that he or she may make changes. 2) File it in the drawer; it is not a useful tool for the ongoing care of the patient. 3) Re-evaluate and update the plan of care continually based on the patient's needs. 4) Inform the family that the plan of care is complete for the duration of the patient's stay.

3) Re-evaluate and update the plan of care continually based on the patient's needs.

When should the MDS be completed? 1) On the day of admission 2) Within the first month of admission 3) Within the first 7 days of admission 4) Prior to discharge from the facility

3) Within the first 7 days of admission

9. An older resident is discharged to home. What should be done with this resident's plan of care? 1. Discard it. 2. Provide a copy to the family. 3. Keep it with the medical record. 4. Send it to the resident's physician.

3. Keep it with the medical record.

4. The nurse prepares a care plan for a newly admitted older resident. What should be done with the plan at this time? 1. Notify the physician so changes can be made. 2. File it in a drawer since it will not be used for ongoing care. 3. Reevaluate and update the plan based on the patient's needs. 4. Inform the family that the plan is complete for the patient's stay.

3. Reevaluate and update the plan based on the patient's needs

Which care provider performs nursing interventions? 1) RN 2) LPN 3) CNA 4) All members

4) All members

Which is a nursing diagnosis? 1) Osteoporosis related to menopause 2) Congestive heart failure related to history of hypertension 3) Non-insulin-dependent diabetes mellitus related to obesity 4) Alteration in thought process related to Alzheimer's disease

4) Alteration in thought process related to Alzheimer's disease

What does the development of a nursing diagnosis depend on? 1) Medical diagnoses 2) Chronic disease processes 3) Goals for the resident's care 4) Data collected in the comprehensive assessment

4) Data collected in the comprehensive assessment

How frequently are goals in long-term care measured? 1) Yearly 2) Weekly 3) Bimonthly 4) Every 30 or 90 days

4) Every 30 or 90 days

How should the nurse explain the minimum data set (MDS) to a new nursing student? 1) Highlights the major issues for each resident 2) Lists specific issues according to each resident 3) Outlines the specific care needed for every resident 4) Identifies standardized information for every resident

4) Identifies standardized information for every resident

How does a nursing diagnosis differ from a medical diagnosis? 1) It is identified by a physician. 2) It identifies specific signs and symptoms. 3) It identifies a specific disease process affecting a specific body system. 4) It describes the impact a specific disease has on a patient's day-to-day activities.

4) It describes the impact a specific disease has on a patient's day-to-day activities.

What is missing from the goal "the resident will walk down the hall every day?" 1) Specificity 2) Timeliness 3) Attainability 4) Measurability

4) Measurability

Which phrase LEAST describes the nursing process? 1) Planned care 2) Patient-centered 3) Adaptable to change 4) Organized according to medical diagnosis

4) Organized according to medical diagnosis

What is NOT a part of assessment documentation? 1) Blood pressure 2) What the resident said 3) The nurse's observation 4) Phone calls to the physician

4) Phone calls to the physician

Which statement best explains the MDS? 1) Refers care providers to standardized plans of care 2) Focuses on care required for specific medical diagnoses 3) Dictates the nursing care that should be provided to every nursing home resident 4) Refers care providers to problem areas that must be addressed in the plan of care

4) Refers care providers to problem areas that must be addressed in the plan of care

Which is an example of assessment data? 1) Altered nutrition 2) Monitoring the resident's oral intake 3) Resident will walk 100 feet each afternoon 4) Resident is complaining of difficulty swallowing

4) Resident is complaining of difficulty swallowing

An 80-year-old patient has the nursing diagnosis of impaired skin integrity related to stasis ulcer on the left ankle. Which would be a goal for this nursing diagnosis? 1) The resident will not have any more leg ulcers. 2) The nurse will change the wound dressing b.i.d. until healed. 3) The nurse will chart any wound drainage and report it to the physician. 4) Stasis ulcer will have decreased redness and granulation tissue evident in 2 weeks.

4) Stasis ulcer will have decreased redness and granulation tissue evident in 2 weeks.

Which is a measurable goal for an older person? 1) The resident will feel better. 2) The resident will feel less nauseated. 3) The resident's appetite will improve. 4) The resident will eat more than 80% of each meal for the next week.

4) The resident will eat more than 80% of each meal for the next week.

A 68-year-old resident has an elevated blood pressure. What would be a goal for this resident's care? 1) The resident's blood pressure will be normal. 2) The resident's blood pressure will not be elevated. 3) The resident's blood pressure will be monitored t.i.d. for 1 week. 4) The resident's blood pressure will be less than 160/90 mm Hg in 1 week.

4) The resident's blood pressure will be less than 160/90 mm Hg in 1 week.

6. The nurse reviews the medical diagnoses for an older patient. In which way should the nursing diagnoses identified for this patient differ from the medical diagnoses? 1. It focuses on prescribed treatments. 2. It identifies specific signs and symptoms. 3. It identifies a specific disease process affecting a body system. 4. It describes the impact a specific disease has on a patient's activities.

4. It describes the impact a specific disease has on a patient's activities.

7. The nurse reviews goals written for an older patient. Which aspect of a goal is missing from the statement "the resident will walk down the hall every day"? 1. Specificity 2. Timeliness 3. Attainability 4. Measurability

4. Measurability

1. The nurse is planning care for an older patient. Which is a measurable goal for this patient? 1. The resident will feel better. 2. The resident will feel less nauseated. 3. The resident's appetite will improve. 4. The resident will eat more than 80% of each meal for the next week.

4. The resident will eat more than 80% of each meal for the next week.

3. The nurse is planning care for an older resident with an elevated blood pressure. What should the nurse identify as a goal for this resident's care? 1. The resident's blood pressure will be normal. 2. The resident's blood pressure will not be elevated. 3. The resident's blood pressure will be monitored three times a day for 1 week. 4. The resident's blood pressure will be less than 160/90 mm Hg in 1 week.

4. The resident's blood pressure will be less than 160/90 mm Hg in 1 week.

2. An older patient has the nursing diagnosis of impaired skin integrity related to a stasis ulcer on the left ankle. Which would be a goal for this nursing diagnosis? 1. The resident will not have any more leg ulcers. 2. The nurse will change the wound dressing b.i.d. until healed. 3. The nurse will chart any wound drainage and report it to the physician. 4. The stasis ulcer will have decreased redness and granulation tissue evident in 2 weeks.

4. The stasis ulcer will have decreased redness and granulation tissue evident in 2 weeks.