Nursing Process: Planning

The following statements are on a patient's nursing care plan. Which of the following statements is written as an outcome? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased mobility in 2 days. c. The patient will demonstrate increased tolerance to activity over the next month. d. The patient will understand needed dietary changes by discharge.

ANS: A

Which of these outcomes would be most appropriate for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications? a. Patient will have one soft, formed bowel movement by end of shift. b. Patient will not take any pain medications this shift. c. Patient will walk unassisted to bathroom by the end of shift. d. Patient will not take laxatives or stool softeners this shift.

ANS: A

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. What factors does the nurse consider when prioritizing interventions? (Select all that apply.) a. Put all the patients' nursing diagnoses in order of priority. b. Consider time as an influencing factor. c. Set priorities based solely on physiological factors. d. Utilize critical thinking. e. Do not change priorities once they've been established.

ANS: A, B, D

After completing a thorough database and analyzing the data to identify any problems, the nurse should proceed to what step of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: B

The nurse describes evidence-based practice as a. Practice based on the evidence presented in court. b. Implementing interventions based on scientific rationale. c. Using standardized care plans. d. Planning care based on tradition.

ANS: B

What is the first step in making a consult? a. Avoid bias by not providing a lot of information based on opinion to the consultant. b. Identify the problem. c. Provide the consultant with relevant information about the problem. d. Ensure that the right professional, with the appropriate knowledge and expertise, is contacted.

ANS: B

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by a. Ambulating in the hallway two times this shift. b. Turning side to back to side with assistance every 2 hours. c. Using the walker correctly to ambulate to the bathroom as needed. d. Using a sliding board correctly to transfer to the bedside commode as needed.

ANS: B

Which intervention is most appropriate for the nursing diagnostic statement, Impaired skin integrity related to shearing forces? a. Administer pain medication every 4 hours as needed. b. Perform the ordered dressing change twice daily. c. Do not document the wound appearance in the chart. d. Keep the bed side rails up at all times.

ANS: B

Which of the following options correctly explains what the nurse should do with the plan of care for a patient after it is developed? a. Place the original copy in the chart, so it cannot be tampered with or revised. b. Communicate the plan of care to all health care professionals involved in the patient's care. c. Send the plan of care to the administration office to be filed. d. Send the plan of care to quality assurance for review.

ANS: B

A hospital's wound nurse consultant made a recommendation for nurses on the unit to continue the patient's dressing changes as previously ordered. The nurses on the unit should incorporate this recommendation into the patient's plan of care by a. Assuming that the wound nurse will perform all dressing changes. b. Requesting that the physician look at the wound herself. c. Including dressing change instructions and frequency in the plan of care. d. Encouraging the patient to perform the dressing changes.

ANS: C

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first by a. Asking physical therapy to assist the patient because of the new injuries. b. Disregarding all previous diagnoses and establishing a new plan of care. c. Reassessing the patient. d. Setting new priorities for the patient.

ANS: C

The nurse recognizes that another term for a collaborative nursing intervention is _____ intervention. a. Dependent b. Independent c. Interdependent d. Physician-initiated

ANS: C

When planning patient care, a goal can be described as a. A statement describing the patient's accomplishments without a time restriction. b. A realistic statement predicting any negative responses to treatments. c. A broad statement describing a desired change in patient behavior. d. An identified long-term nursing diagnosis.

ANS: C

A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems that a nurse can treat. While developing the plan of care, which nursing diagnosis is the highest priority for this patient? a. Risk for impaired skin integrity b. Risk for infection c. Spiritual distress d. Reflex urinary incontinence

ANS: D

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement, Risk for falls? a. Encourage patient to remain in bed most of the shift. b. Keep all side rails down at all times. c. Place patient in room away from the nurses' station if possible. d. Assist patient into and out of bed every 6 hours or as tolerated.

ANS: D

A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? a. Individualize the care plan only according to the patient's needs. b. Request that the son leave at bedtime, so the patient can rest. c. Suggest that a female member of the family stay with the patient. d. Involve the son in the plan of care as much as possible.

ANS: D

A registered nurse administers pain medication to a patient suffering from fractured ribs. What type of nursing intervention is this nurse implementing? a. Collaborative b. Independent c. Interdependent d. Dependent

ANS: D

The nurse is caring for seven patients this shift. After completing their assessments, the nurse states that he doesn't know where to begin in developing care plans for these patients. Which of the following is an appropriate suggestion by another nurse? a. "Choose all the interventions and perform them in order of time needed for each one." b. "Make sure you identify the scientific rationale for each intervention first." c. "Decide on goals and outcomes you have chosen for the patients." d. "Begin with the highest priority diagnoses, then select appropriate interventions."

ANS: D

Which intervention is most appropriate for the nursing diagnostic statement, Impaired verbal communication related to loss of facial motor control and decreased sensation? a. Obtain an interpreter for the patient as soon as possible. b. Assist the patient in performing swallowing exercises each shift. c. Ask the family to provide a sitter to remain with the patient at all times. d. Provide the patient with a writing board each shift.

ANS: D

Which patient outcome statement includes all seven guidelines for writing goal and outcome statements? a. The patient will ambulate in hallways. b. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort. c. The nurse will monitor the patient's heart rhythm continuously this shift. d. The patient will feed self at all mealtimes today without complaints of shortness of breath.

ANS: D