chapter 14 review

The primary purpose of the evaluating phase of the care planning process is to determine whether 1. Desired outcomes have been met. 2. Nursing activities were carried out. 3. Nursing activities were effective. 4. Client's condition has changed.

1. Desired outcomes have been met.

Which of the following demonstrates appropriate use of guidelines in implementing nursing interventions? Select all that apply. 1. No interventions should be carried out without the nurse having clear rationales. 2. Always follow the primary care provider's orders exactly, without variation. 3. Encourage all clients to be as dependent as desired and allow the nurse to perform care for them. 4. When possible, give the client options in how interventions will be implemented. 5. Each intervention should be accompanied by client teaching.

1. No interventions should be carried out without the nurse having clear rationales. 4. When possible, give the client options in how interventions will be implemented. 5. Each intervention should be accompanied by client teaching.

Which of the following is true regarding the relationship of implementing to the other phases of the nursing process? 1. The findings from the assessing phase are reconfirmed in the implementing phase. 2. After implementing, the nurse moves to the diagnosing phase. 3. The nurse's need for involvement of other health care team members in implementing occurs during the planning phase. 4. Once all interventions have been completed, evaluating can begin.

1. The findings from the assessing phase are reconfirmed in the implementing phase.

Which of the following represents application of the components of evaluating? 1. Goal achievement must be written as either completely met or unmet. 2. Data related to expected outcomes must be collected. 3. If the outcome was achieved, conclude that the plan was effective. 4. After determining that the outcome was not met, start over with a new nursing care plan.

2. Data related to expected outcomes must be collected.

The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following? 1. Delete the diagnosis since the problem has not occurred. 2. Keep the diagnosis since the risk factors are still present. 3. Modify the nursing diagnosis to Impaired Mobility. 4. Demote the nursing diagnosis to a lower priority.

2. Keep the diagnosis since the risk factors are still present.

If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to a client need reported over the intercom system on each shift, which process does this reflect? 1. Structure evaluation 2. Process evaluation 3. Outcome evaluation 4. Audit

2. Process evaluation

The care plan calls for administration of a medication plus client education on diet and exercise for high blood pressure. The nurse finds the blood pressure extremely elevated. The client is very distressed with this finding. Which nursing skill of implementing would be needed most? 1. Cognitive 2. Intellectual 3. Interpersonal 4. Psychomotor

3. Interpersonal

When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first? 1. Carrying out nursing interventions 2. Determining the need for assistance 3. Reassessing the client 4. Documenting interventions

3. Reassessing the client

Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out? 1. When the activity is routine (e.g., raising the bed rails) 2. When the activity occurs at regular intervals (e.g., turning the client in bed) 3. When the activity is to be carried out immediately (e.g., a stat medication) 4. It is never acceptable

4. It is never acceptable

An element of quality improvement, rather than quality assurance, is which of the following? 1. Focus is on individual outcomes 2. Evaluates organizational structures 3. Aims to confirm that quality exists 4. Plans corrective actions for problems

4. Plans corrective actions for problems