PrepU Ch 16

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

A) Individualize the plan to the client.

These nursing diagnoses appear on a client's care plan. In what order will the nurse prioritize them? 1 Impaired Swallowing 2 Fluid Volume Deficit 3 Risk for Impaired Skin Integrity 4 Altered Body Image

1. Impaired Swallowing 2. Fluid Volume Deficit 3. Risk for Impaired Skin Integrity 4. Altered Body Image

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) A standardized care plan B) An order set C) Guidelines D) An algorithm

A) A standardized care plan

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

A) Client will have formed stools within 24 hours.

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

A) Client will not leave the premises without a caregiver.

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

A) Nurse-initiated interventions are derived from the nursing diagnosis.

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

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

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? A) Supportive B) Psychosocial C) Coordinating D) Supervisory

A) Supportive

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client? A) The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. B) The client will express an understanding of strategies for managing fatigue and shortness of breath. C) The client will ambulate 100 feet without supplementary oxygen or mobility aids. D) The client will demonstrate the correct use of a metered-dose inhaler.

A) The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath.

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

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

Which is an example of a psychomotor outcome? A) Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. B) Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. C) The client will verbalize understanding of the need to continue to take medications as prescribed. D) The client's skin will remain smooth, moist, and without breakdown or ulceration.

A) Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

The nurse recognizes that identifying outcomes/goals must include: A) involvement of the client and family. B) input from the physician. C) input from the multidisciplinary team. D) involvement of the nurse manager and other staff nurses.

A) involvement of the client and family.

The nurse should derive the outcomes for a client's care plan from: A) the problem statement of the nursing diagnosis. B) the defining characteristics in the nursing diagnosis statement. C) assessment data gleaned from the physician's progress notes. D) assessment data provided by the multidisciplinary team.

A) the problem statement of the nursing diagnosis.

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

B) "Please tell me your thoughts about treating this diagnosis."

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

B) Date the nursing interventions when written and when the plan of care is reviewed.

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

B) Nurses do carry out interventions in response to a physician's order.

A computerized information system developed to classify client outcomes is the: A) NANDA-International list B) Nursing Outcome Classification system C) International Classification of Diseases D) Clinical Care Classification System

B) Nursing Outcome Classification system

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." The nurse should identify this statement as an example which element of nursing practice? A) Nursing diagnosis B) Outcome C) Intervention D) Evaluation

B) Outcome

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

B) Seek research about the disorder.

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

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

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome? A) The nurse has not made any error in writing the outcome. B) The nurse has omitted the time frame. C) The nurse has omitted the defining characteristics. D) The outcome should indicate what the nurse will do.

B) The nurse has omitted the time frame.

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

B) identifies factors causing undesirable response and preventing desired change.

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? A) Client reports no headache. B) Client is drowsy after lunch. C) Client is normotensive. D) Client lipids are within range.

C) Client is normotensive.

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

C) Client will ambulate safely with walker in the room within 3 days of physical therapy.

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? A) Process B) Structure C) Outcome D) Cost-effectiveness

C) Outcome

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

C) Psychomotor

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

C) intervention.

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

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

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

D) Educational

What are specific measurable and realistic statements of goal attainment? A) Nursing diagnoses B) Nursing interventions C) Evaluations D) Outcomes

D) Outcomes

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan? A) Initial B) Ongoing C) Discharge D) Standardized

D) Standardized

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

D) Teach the client how to splint an abdominal incision when coughing and deep breathing.

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: A) support system. B) medical orders. C) past medical history. D) condition.

D) condition.

Which are characteristics of appropriate client outcome statements? Select all that apply. Measurable Realistic Specific Short-term Broad in scope

Measurable Realistic Specific

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

A) Add the nursing diagnosis: Risk for Self-Harm.

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

A) Cutting up food and opening drink containers for the client

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? A) Encourage hourly use of the incentive spirometer. B) Promote oral fluid intake between meals. C) Provide oral pain medication before ambulation. D) Reassess in 4 hours and document the findings.

A) Encourage hourly use of the incentive spirometer.

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? A) Narcotic analgesic to treat pain B) Septic workup due to blood pressure and heart rate elevation C) Isolation for suspected respiratory illness D) Acetaminophen to treat pain and fever

A) Narcotic analgesic to treat pain

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

A) On the client's admission to the hospital

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? A) Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. B) The nurse will help the client ambulate the length of the hallway once a day. C) Offer to help the client walk the length of the hallway each day. D) The client will become mobile within a 24-hour period.

A) Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

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? A) Perform hourly neurovascular assessment. B) Elevate the injured arm on a pillow. C) Apply ice to the casted extremity. D) Give prescribed pain meds.

A) Perform hourly neurovascular assessment.

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: A) a clinical pathway. B) an order set. C) an algorithm. D) a protocol.

A) a clinical pathway.

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

A) a guideline.

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

A) discharge planning.

Which outcome for a client with a new colostomy is written correctly? A) Explain to the client the proper care of the stoma by 3/29/20. B) The client will know how to care for the stoma by 3/29/20. C) The client will demonstrate proper care of the stoma by 3/29/20. D) The client will be able to care for stoma and cope with psychological loss by 3/29/20.

C) The client will demonstrate proper care of the stoma by 3/29/20.