25 Quiz 7 - The Nursing Process - Planning

A nurse is devising a care plan for a client with complex health issues & current acute health problems. Nursing interventions must meet which of the following criteria? (Select all that apply.) A. Congruent with the client's values, beliefs, & culture B. Within established standards of care C. Based on scientific & medical knowledge D. Achievable with the resources available

Answer: • Congruent with the client's values, beliefs, & culture • Within established standards of care • Achievable with the resources available Rationale: The plan must be based on nursing knowledge & experience or knowledge from relevant sciences (based on rationale). Other criteria for interventions are that they must be safe & appropriate for the client's age, health, & condition, & they must be collaborative with other therapies. Implementation

A nurse is just starting a job at a new hospital. As part of the orientation process, the nurse must review the hospital's policies & procedures for nursing care. Standards of care, standardized care plans, protocols, policies, & procedures are developed & accepted by the nursing staff for which of the following reasons? (Select all that apply.) A. Make sure all clients have the same types of care B. Ensure that minimally accepted standards are met C. Promote efficient use of the nurse's time D. Eliminate care disparities among clients

Answer: • Ensure that minimally accepted standards are met • Promote efficient use of the nurse's time Rationale: Ensuring that all clients receive the same type of care is not appropriate as care must be individualized to meet the client's needs. Standardized approaches to care planning are common in many health care agencies. Implementation

One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. The modifier in this intervention is which of the following? A. 60 to 90 degrees during feeding times B. Position in chair C. Upright in a chair D. Impaired swallowing

Answer: 1 Rationale: Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. In this case, defining "upright" as 60 to 90 degrees & "during feeding times" gives when this should be done. The words "positioning" & "upright" are not descriptive enough for modifiers. Impaired swallowing is the NANDA label. Implementation

When implementing a care plan, the nurse involves a client who is ready for discharge in the planning. One of the goals is that the client will have improved mobility. Which of the following might be an appropriate desired outcome statement for this goal? A. Client will ambulate without a walker by 6 weeks. B. Client will ambulate freely in house. C. Client will not fall. D. Client will have freer movement in daily activities.

Answer: 1 Rationale: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulating without a walker by a certain date is specific as well as measurable. "Ambulate freely" does not give a time frame, therefore it is not as specific. Goals stated as "will not fall" or "have freer movement in daily activities" are too vague, have no time limit, & do not give the nurse a good set of criteria to evaluate the goal. Planning

A nurse is helping a client with planning following a surgery in which the client had a permanent colostomy placed. Which of the following would be considered a short-term goal for this client? Client will: A. Be able to state signs & symptoms of skin breakdown. B. Have a formed bowel movement every 2 days. C. Identify food sources that are problematic for the situation. D. Maintain a positive self-esteem.

Answer: 1 Rationale: Initially, a client with a new colostomy must be aware of the signs & symptoms of skin breakdown & have a good knowledge base about basic skin care regimen. This should be accomplished before the client leaves the hospital in order to prevent problems at home. Normal bowel elimination patterns may not be present for some time, depending on the client's diet & activity level. This would be a long-term goal. Knowledge about what particular foods may cause problems for this client would be information the client gathers as time goes on. What perhaps was not a problem prior to the surgery may now cause gas, bloating, diarrhea, or constipation. Overcoming body image changes for this client may take some time & this would be considered a long-term goal. Planning

A student nurse is working on a care plan for an assigned client. One of the interventions the student nurse would like to include in the plan is to assist the client with ambulation. Which of the following is the best way to state this plan? A. Assist client with ambulation. B. Ambulate with client, using a gait belt, twice daily for 15 minutes. C. Make sure client understands the rationale for using the gait belt. D. Client will ambulate in hallway twice daily.

Answer: 2 Rationale: A written intervention should include a verb, conditions, & modifiers, plus a time element. Identifying what to do (ambulate), how to do it (with a gait belt), & how long (twice daily for 15 minutes) is the most precise statement. "Client will ambulate in the hallway" is a goal statement, not an intervention. Implementation

A client with Parkinson's disease is working to improve fine motor skills, especially for completing activities of daily living. Which of the following would be considered a collaborative intervention? A. Provide assistance as needed with dressing & grooming. B. Provide assistive devices & educate client to use grab bar & large handled utensils. C. Make sure lighting & space are adequate for client. D. Administer medications to improve muscle tone.

Answer: 2 Rationale: Collaborative interventions are actions the nurse carries out with other health team members, such as physical therapists, social workers, dietitians, & physicians. Collaborative nursing activities reflect the overlapping responsibilities of, & collegial relationships between, health personnel. Providing assistive devices & educating on their proper use would fall into the discipline of physical/occupational therapy, although the nurse will have to assist with reinforcing the teaching & information. Providing assistance & attending to the client's space would be independent interventions. Administering medications would be a dependent intervention. Implementation

A nurse is working in the neonatal intensive care unit. A newly admitted, premature baby is having difficulty maintaining body temperature. The nurse implements several actions to prevent further complications. The nurse finds these actions in what type of document? A. Standardized care plan B. Protocol C. Standards of care D. Policy & procedure manual

Answer: 2 Rationale: Protocols are preprinted to indicate the actions commonly required for a particular group of clients (in this case, premature infants). Protocols may include both physicians' orders & nursing interventions. Standardized care plans are preprinted guides for the nursing care of a client who has a need that arises frequently in the agency—or all nursing diagnoses associated with a particular medical condition. In this situation, the nurse is not working from the written care plan, since the baby has just been admitted. Standards of care describe nursing actions for clients with similar medical conditions rather than individuals, & they describe achievable rather than ideal nursing care. Policies & procedures are developed to govern the handling of frequently occurring situations. Implementation

A hospital is implementing the use of NIC (Nursing Interventions Classification) taxonomy. This taxonomy will: A. Help the nurse with documentation of the care plan. B. Still require that the nurse use sound judgment & knowledge of the client. C. Match nursing diagnoses to exact interventions. D. Help the nurse choose activities that are individualized to the client.

Answer: 2 Rationale: The NIC taxonomy, like NOC, is similar to NANDA diagnoses— broadly stated interventions that are standardized in language & generalized in nature. Each nursing diagnosis contains suggestions for several interventions under the NIC taxonomy, & nurses must select the appropriate interventions based on their judgment & knowledge of the client. The NIC taxonomy may or may not help with documentation. Although it would utilize standard language for all nurses & offer suggestions of interventions for each diagnosis, finding the most appropriate interventions still requires individualization for each client. This taxonomy is general & standardized & must be tailored to fit the needs, outcomes, & goals of the individual client. Implementation

A nurse is seeing a home health client who requires extensive treatment for chronic airway disease. According to the care plan, the client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, & is 40 miles away from a hospital. When setting priorities, the home health nurse will: A. Make sure that he or she is able to get to the client's home. B. Assist the client in finding an alternative plan for the therapy. C. Tell the client that this therapy will be impossible to receive. D. Make arrangements to have the client moved to a long-term care facility.

Answer: 2 Rationale: The nurse must consider a variety of factors when assigning priorities, including resources available to the nurse & client. Factors in this case include the distance between the client's home & the hospital & the fact that therapy is ordered on a twice daily basis. Driving 80 miles two times a day may not be feasible, but perhaps there are other alternatives that could be considered (e.g., a neighbor who might be willing to drive the client, or someone in the area who may be able to assist with the therapy). Telling the client that the therapy is impossible or making arrangements for the client to move is premature at this point in time. Implementation

A client has been in the hospital for several days following a CVA (cerebrovascular accident). One of the diagnoses formulated for this client is Risk for aspiration, related to neuromuscular dysfunction. Of the following interventions, which includes a rationale? A. Have suction equipment available at all times. B. Clear secretions from oral/nasal passageways as needed. C. Keep client in low-Fowler's position to prevent reflux. D. Provide frequent assessment for presence of obstructive material in mouth & throat.

Answer: 3 Rationale: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain "why" an intervention would be implemented. Keeping the client in a position with the head elevated 30 to 45 degrees helps prevent the risk of reflux (food/liquids returning up through the esophagus after having been swallowed). None of the other options state "why" they are being performed. Implementation

A client is admitted for a scheduled, elective hip replacement after having pain & limited mobility for several years. The client's plan of care would most likely be taken from which of the following? A. Informal nursing care plan B. Formal nursing care plan C. Standardized care plan D. Individualized care plan

Answer: 3 Rationale: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. For example, all clients undergoing hip replacement surgery would have basic, similar needs or problems such as pain, skin integrity disruption, risk for infection, decreased mobility, or risk for fall or injury. An informal nursing care plan is a strategy for action that exists in the nurse's mind. A formal nursing care plan is a written or computerized guide that organizes information about the client's care. An individualized care plan is tailored to meet the unique needs of a specific client—needs not addressed by the standardized plan. Implementation

A client has been seeing a nurse practitioner for counseling following a rape. A long-term goal for this client would be which of the following? A. Client will devise a list of phone numbers for support people. B. Client will be able to share feelings of fear with counselor. C. Client will return to level of purpose & functioning as before the rape. D. Client will state signs & symptoms of physical trauma.

Answer: 3 Rationale: Clients who have been raped may require extensive counseling & therapy work to deal with the assault. Some may never regain their prior level of functioning as before the attack, & for most, it will require some time to do this. Short-term goals are the other options listed—those that the client can implement in the first few days following the rape in order to feel safe & share feelings of fear & anger. The physical injuries following a rape may be minor, but the client should know to watch for any unusual symptoms (i.e., discharge, bruising, or bleeding). Planning

A nurse is working with a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Of the following listed, which would be considered an observation intervention? A. Turn & reposition client every 2 hours. B. Cushion bony prominences with soft foam while in bed. C. Provide ongoing assessment for skin breakdown every shift. D. Apply lotion to dry skin twice daily.

Answer: 3 Rationale: Observations include assessments made to determine whether a complication is developing as well as observations of the client's responses to nursing & other therapies. Assessment for skin breakdown would fall under this category. Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Turning & repositioning as well as cushioning bony prominences would help prevent any further skin breakdown. Application of lotion or other treatments to areas of skin impairment would be considered a treatment intervention. Implementation

The client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care. Of the following, who might be involved with the ongoing planning of this client's care? A. The admitting nurse is still responsible B. All nurses who work with the client C. Everybody involved in this client's care D. The client & the client's support system

Answer: 3 Rationale: Planning is basically the nurse's responsibility but input from the client & support persons is essential if a plan is to be effective. In this case, therapies from other disciplines (occupational, physical, speech, etc.) would be involved since the client is in a comprehensive rehabilitation center. The client's support people & caregivers are also going to be involved in the plan of care, but not exclusively. Implementation

A child is admitted to the hospital for complications from diabetes. Which of the following nursing diagnoses will the nurse focus on as priority? A. Fear, related to unfamiliar surroundings B. Ineffective management of therapeutic regimen, related to complexity C. Altered nutrition, less than body requirements, related to inability to maintain glucose level D. Risk for infection, related to circulatory changes, secondary to high blood glucose levels

Answer: 3 Rationale: Prioritizing is the process of establishing sequencing for addressing nursing interventions. The nurse in this case must decide which diagnosis requires attention first. Physiologic needs are basic to life & receive higher priority than the need for security & education. Identifying a potential problem, but one that is not present, would take the lowest priority. Nursing diagnosis

A nurse moves to a new city & begins work in a hospital that utilizes the NOC classification taxonomy. The nurse understands that this system can be compared to which of the following? A. Nursing diagnosis statement B. Planning portion of the care plan C. Goal statement of the traditional care plan D. Implementation phase of the care plan

Answer: 3 Rationale: The Nursing Outcomes Classification (NOC) describes client outcomes that respond to nursing interventions. The nursing diagnosis statement must follow the NANDA format. Goal setting is part of the planning, but the NOC outcome is narrower in use than general planning. Implementation is compared to the Nursing Interventions Classification (NIC) taxonomy. Planning

A client has just given birth to a premature infant via emergency C-section. Which of the following nursing diagnoses would receive the lowest priority for the new mother? A. Acute pain, related to surgical procedure B. Impaired skin integrity, related to new incision C. Anxiety, related to unpredictability of newborn's health D. Risk for infection, related to surgical incision

Answer: 4 Rationale: A problem identified as potential (at risk for development) receives the lowest priority since it is currently not present. It is a potential for this client & therefore must be assessed & monitored as a possible complication. The other options are active problems & would receive a higher priority for care. Nursing diagnosis

A client is admitted for complications following a routine diagnostic procedure of the colon. The type of care plan that will most likely be implemented for this client is which of the following? A. Informal nursing care plan B. Formal nursing care plan C. Standardized care plan D. Individualized care plan

Answer: 4 Rationale: An individualized care plan is tailored to meet the unique needs of a specific client— needs that are not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine procedure—something that is unplanned & a rare occurrence & must fit with the needs of the client. An informal nursing care plan is a strategy for action that exists in the nurse's mind. A formal nursing care plan is a written or computerized guide that organizes information about the client's care. A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. Implementation

A client is on a regular surgical unit following a knee repair. When caring for the client, the nurse performs independent as well as dependent interventions. Which of the following is an example of a dependent intervention? A. Repositioning the client every 2 hours B. Assisting the client with transfers to the bathroom C. Providing ongoing physical assessment, especially of the incisional sites D. Administering medications for pain

Answer: 4 Rationale: Dependent interventions are those activities carried out under the physician's orders or supervision or according to specified routines. The nurse is responsible for assessing the need for & administering medications, but the physician prescribes them. All other options listed are examples of independent interventions—those activities that the nurse is licensed to initiate on the basis of knowledge & skills. Implementation

A nurse is caring for a client in a trauma ICU in the middle of the night. The client is having difficulty maintaining blood pressure, & the nurse administers a routinely used medication for this problem. This is an example of the nurse implementing which of the following? A. A STAT order B. A one-time order C. A p.r.n. order D. A standing order

Answer: 4 Rationale: Standing orders are a written document about policies, rules, regulations, or orders regarding client care. Standing orders give the nurses authority to carry out specific actions under certain circumstances, often when a physician is not immediately available. A STAT order is one that must be carried out immediately. A one-time order is for an action to be done only once; p.r.n. is pro re nata—Latin for "as needed." Implementation

A nursing diagnosis of Fluid volume deficit, related to active fluid loss, secondary to diarrhea has been formulated for a client. An appropriately written goal statement for this diagnosis would be which of the following? A. Client will drink more fluids by tomorrow. B. Client will have good skin turgor. C. Client will have moist mucous membranes. D. Client will have intake of at least 1000 mL within 24 hours.

Answer: 4 Rationale: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress. Modifiers like "more" & "good" could be more specific, & all options must have a time frame for evaluating the desired performance. Planning

A client with beginning stages of Alzheimer's disease is being admitted to an assisted living facility. The nurse is helping the client & family with the adjustment process & planning long- & short-term goals for the client as well as the family. An appropriate, realistic short-term goal for this client would be which of the following? A. Client will not wander out of facility. B. Client will maintain a normal weight. C. Client will be able to verbalize feelings of anger, fear, & trust, when appropriate. D. Client will be oriented to the surroundings.

Answer: 4 Rationale: This type of client should be oriented to his new surroundings within a few days. The client should know which room is his, where the meals are served, where the bathroom is, & so on. All other options listed would be either unrealistic (no wandering, & verbalizing feelings are probably not within the realm of possibilities) or long-term goals (maintaining a normal weight would be an ongoing, long-term goal). Planning