UT 2 Funds The Nursing Process Chapter 10-15

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. A. A nurse sits down with a patient and prioritizes existing diagnoses. B. A nurse assesses a woman for postpartum depression during routine care. C. A nurse plans interventions for a patient who is diagnosed with epilepsy. D. A busy nurse takes time to speak to a patient who received bad news. E. A nurse reassesses a patient whose PRN pain medication is not working. F. A nurse coordinates the home care of a patient being discharged.

b, d, e (Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.)

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a plan of care for this patient. Which QSEN competency does this action represent? A. Patient-centered care B. Evidence-based practice C. Quality improvement D. Informatics

c. (Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.)

Read the following patient scenario and identify the step of the nursing process represented by each numbered and boldfaced nursing activity. Annie seeks the help of the nurse in the student health clinic because she suspects that her roommate, Angela, suffered date rape. She is concerned because Angela chose not to report the rape and does not seem to be coping well. (1) After talking with Annie, the nurse learns that although Angela blurted out that she had been raped when she first came home, since then she has refused verbalization about the rape ("I don't want to think or talk about it"), has stopped attending all college social activities (a marked change in behavior), and seems to be having nightmares. After analyzing the data, the nurse believes that Angela might be experiencing (2) rape-trauma syndrome: silent reaction. Fortunately, Angela trusts Annie and is willing to come to the student health center for help. A conversation with Angela confirms the nurse's suspicions, and problem identification begins. The nurse talks further with Angela (3) to develop some treatment goals and formulate outcomes. The nurse also begins to think about the types of nursing interventions most likely to yield the desired outcomes. In the initial meeting with Angela, (4) the nurse encourages her expression of feelings and helps her to identify personal coping strategies and strengths. The nurse and Angela decide to meet in 1 week (5) to assess her progress toward achieving targeted outcomes. If she is not making progress, the plan of care might need to be modified.

(1) assessing: the collection of patient data. (2) identification of a nursing diagnosis: a health problem that independent nursing intervention can resolve. (3) planning: outcome identification and related nursing interventions. (4) implementing: carrying out the plan of care. (5) evaluating: measuring the extent to which Angela has achieved targeted outcomes.

You analyze the data just described and write the nursing diagnosis: Unrelieved pain related to a fear of taking pain-relieving medications. The patient agrees that this is becoming a problem. What step in the nursing process is this?

Diagnose

Define a problem statement

Identifies what is unhealthy about the patient, indicating the need for change (clear, concise statement of the patient's health problem)

After asking the patient about his experiences with pain-relieving medications, you explain that although many of these drugs are addictive when abused, there is no harm if they are taken as prescribed postoperatively. You also explain that it is important for him to experience enough pain relief to be able to cough and deep breathe, ambulate, and do other things important to his recovery. You suggest that the medication will be most effective if taken before his pain peaks and becomes intense. You administer the prescribed medication for pain when the patient indicates that he is willing to give it a try. What step in the nursing process is this?

Implement

A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. A. Basing patient care on continuous healing relationships B. Customizing care to reflect the competencies of the staff C. Using evidence-based decision making D. Having a charge nurse as the source of control E. Using safety as a system priority F. Recognizing the need for secrecy to protect patient privacy

a, c, e (Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for transparency should be recognized.)

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. A. Monitoring patient status every hour B. Using intuition to troubleshoot patient problems C. Turning a patient on bed rest every 2 hours D. Becoming a nurse mentor to a student nurse E. Administering pain medication ordered by the physician F. Becoming involved in community nursing events

a, c, e. (Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They are established by authority, custom, or consent.)

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. A. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. B. The nurse uses a binary decision tree for stepwise assessment and intervention. C. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. D. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. E. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. F. The nurse uses a decision tree that provides intense specificity and no provider flexibility.

a, c. (A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.)

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. A. The nurse uses critical thinking skills to plan care for a patient. B. The nurse correctly administers IV saline to a patient who is dehydrated. C. The nurse assists a patient to fill out an informed consent form. D. The nurse learns the correct dosages for patient pain medications. E. The nurse comforts a mother whose baby was born with Down syndrome. F. The nurse uses the proper procedure to catheterize a female patient.

a, d (Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.)

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. A. The nurse carefully removes the bandages from a burn victim's arm. B. The nurse assesses a patient to check nutritional status. C. The nurse formulates a nursing diagnosis for a patient with epilepsy. D. The nurse turns a patient in bed every 2 hours to prevent pressure ulcers. E. The nurse checks a patient's insurance coverage at the initial interview. F. The nurse checks for community resources for a patient with dementia.

a, d, f. (During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.)

The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?" Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. A. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." B. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" C. "I'm a student nurse and need to develop the skill of assessing your health status and need for nursing care." D. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate." E. "We need to check your health status and see what kind of nursing care you may need." F. "We need to see if you require a referral to a physician or other health care professional.

a, e, f (Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patient's strengths and promotes optimum functioning, independence, and well-being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.)

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." Which of the following comments is the nurse most likely to hear from the instructor? "Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue." "Job well done . . . you've identified this problem early and we can manage it before it becomes more acute." "Is this an actual or a possible diagnosis?" "This is a medical, not a nursing problem."

a. (A data cluster is a grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. There may be a reason for the lack of a bowel movement for 2 days, or it might be this individual's normal pattern.)

To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to: Compare this reading to standards. Check the taxonomy of nursing diagnoses for a pertinent label. Check a medical text for the signs and symptoms of high blood pressure. Consult with colleagues.

a. (A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.)

A nurse is assessing a 15-year-old female patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: A. Clinical judgment B. Clinical reasoning C. Critical thinking D. Blended competencies

a. (Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical/legal skills combined with the willingness to use them creatively and critically when working with patients.)

A nurse is preparing a clinical outcome for a 32-year-old female runner who is recovering from a stroke that caused right-sided paresis. An example of this type of outcome is: A. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. B. By 8/15/15, patient will be able to use right arm to dress, comb hair, and feed herself. C. Following physical therapy, patient will begin to gradually participate in walking/running events. D. By 8/15/15, patient will verbalize feeling sufficiently prepared to participate in running events.

a. (Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.)

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident with the procedure. What would be the student's best response? A. Tell the RN that he or she lacks the technical competencies to change the dressing independently. B. Assemble the equipment for the procedure and follow the steps in the procedure manual. C. Ask another student nurse to work collaboratively with him or her to change the dressing. D. Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

a. (Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the plan of care. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.)

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? A. "You made an inference that she is fine because she has no complaints. How did you validate this?" B. "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." C. "Sometimes everyone gets lucky. Why don't you try to help another patient?" D. "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"

a. (The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving)

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? A. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. B. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. C. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it's time to champion intuitive, creative thinking! D. It's simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

a. (Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference)

A nurse uses critical thinking skills to focus on the care plan of an elderly patient who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. A. It functions independently of nursing standards, ethics, and state practice acts. B. It is based on the principles of the nursing process, problem solving, and the scientific method. C. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. D. It is not designed to compensate for problems created by human nature, such as medication errors. E. It is constantly re-evaluating, self-correcting, and striving for improvement. F. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

b, c, e (Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve)

An RN working on a busy hospital unit delegates patient care to unlicensed assistive personnel (UAPs). Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. A. Performing the initial patient assessments B. Making patient beds C. Giving patients bed baths D. Administering patient medications E. Ambulating patients F. Assisting patients with meals

b, c, e, f. (Performing the initial patient assessment and administering medications are the responsibility of the registered nurse. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.)

A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. Bronchial pneumonia Impaired gas exchange Ineffective airway clearance Potential complication: sepsis Infection related to pneumonia Risk for septic shock

b, c, f. (Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.)

A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. The nurse uses the nursing interview to collect patient data. The nurse analyzes data collected in the nursing assessment. The nurse develops a care plan for the patient. The nurse points out the patient's strengths. The nurse assesses the patient's mental status. The nurse identifies community resources to help his family cope.

b, d, f. (The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.)

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? Risk for Impaired Skin Integrity Related to prescribed bedrest As evidenced by As evidenced by reddened areas of skin on the heels and back

b. ("Related to prescribed bedrest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.)

A nurse writes nursing diagnoses for patients and their families visiting a community health clinic. Which nursing diagnoses are correctly written as three-part nursing diagnoses? (1) Disabled Family Coping related to lack of knowledge about home care of child on ventilator (2) Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-pound weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height weight charts (3) Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" (4) Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?," "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" (5) Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression A. (1) and (3) B. (2) and (4) C. (1), (2), and (3) D. All of the above

b. (1. is a two-part diagnosis, 3. is written in terms of needs and not an unhealthy response, and 5. is a legally inadvisable statement.)

A nurse makes a clinical judgment that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or similar situation. The nurse has formulated what type of nursing diagnosis? Actual Risk Possible Wellness

b. (A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.)

A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68-year-old male patient. What type of diagnosis does this intervention seek to confirm? A. Actual B. Possible C. Risk D. Collaborative

b. (An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.)

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the first nursing action that should be taken prior to performing this care? A. Administer pain medication. B. Reassess the patient. C. Prepare the equipment. D. Explain the procedure to the patient.

b. (Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and if necessary administer pain medications.)

A nurse is performing an initial comprehensive assessment of an 84-year-old male patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? A. Maslow's human needs B. Gordon's functional health patterns C. Human response patterns D. Body system model

b. (Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.)

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? A. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" B. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." C. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." D. "Don't worry about learning all of the questions to ask. Every agency has its own assessment form you must use."

b. (Once you learn what constitutes the minimum data set, you can adapt this to any patient situation. It is not true that each assessment is the same even when you are using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard agency assessment tools does not allow for individualized patient care or critical thinking.)

Nurses use the Nursing Interventions Classification Taxonomy structure as a resource when planning nursing care for patients. What information would be found in this structure? A. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions B. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings C. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention D. A complete list of reimbursable charges for each nursing intervention

b. (The Nursing Interventions Classification Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.)

A nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? A. Offer the patient 60 mL fluid every 2 hours while awake. B. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. C. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/15 D. At the next visit, 12/23/15, the patient will know that he should drink at least 3 liters of water per day.

b. (The outcomes in a and c make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60 mL fluid every 2 hours while awake." Correct: "The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/15." The outcome in d makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware.")

. After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? No problem Possible problem Actual nursing diagnosis Clinical problem other than nursing diagnosis

b. (When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.)

A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient appreciates or values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? A. Cognitive B. Psychomotor C. Affective D. Physical changes

c. (Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).)

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? A. The nurse judges whether the patient database is adequate to address the problem. B. The nurse considers whether or not to suggest a counseling session for the patient. C. The nurse reassesses the patient and decides how best to intervene in her care. D. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

c. (The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.)

The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do? A. Inform the charge nurse. B. Inform the surgeon. C. Validate the finding. D. Document the finding.

c. (The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate, thus all data should be validated before documentation if there are any doubts about accuracy)

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the RN? A. Allow the UAPs to do the admission assessment and report the findings to the RN. B. Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. C. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. D. Contact his or her labor representative and complain about this practice.

c. (The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.)

A nurse develops a detailed plan of care for a 16-year-old female who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? A. "You know your personal situation better than I do, so I will respect your wishes." B. "If you don't accept these services, your baby's health will suffer." C. "Let's take a look at the plan again and see if we can adjust it to fit your needs." D. "I'm going to assign your case to a social worker who can explain the services better."

c. (When a patient does not follow the plan of care despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the plan of care is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.)

When helping a patient turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of what type of planning? A. Initial planning B. Standardized planning C. Ongoing planning D. Discharge planning

c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An example of an affective outcome for this patient is: A. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. B. By 6/12/15, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. C. By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3″ to 2.5″). D. By 6/12/15, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. (Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills. c is an outcome describing a physical change in the patient.)

A student nurse is organizing clinical responsibilities for an 84-year-old female patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? A. Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. B. Schedule the testing and meal planning first and complete hygiene as time permits. C. Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. D. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

d. (As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.)

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? (1) Ineffective Coping related to inability to maintain marriage (2) Defensive Coping related to loss of job and economic security (3) Altered Thought Processes related to panic state (4) Decisional Conflict related to placement of parent in a long-term care facility (1) and (2) (3) and (4) (1), (2), and (3) All of the above

d. (Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.)

A nurse is counseling a 60-year-old female patient who refuses to look at or care for a new colostomy. She tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? Collaborative problem Interdisciplinary problem Medical problem Nursing problem

d. (Nursing Problem, because it describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.)

When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate? A. Correct the initial assessment form. B. Redo the initial assessment and document current findings. C. Conduct and document an emergency assessment. D. Perform and document a focused assessment of skin integrity.

d. (Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.)

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? A. Comprehensive B. Initial C. Time-lapsed D. Quick priority

d. (Quick priority assessments (QPA) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care agency or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.)

A student health nurse is counseling a female college student who wants to lose 20 pounds. The nurse develops a plan to increase the student's activity level and decrease the consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 pounds, the student has lost only 1 pound. Which is the best nursing response? A. Congratulate the student and continue the plan of care. B. Terminate the plan of care since it is not working. C. Try giving the student more time to reach the targeted outcome. D. Modify the plan of care after discussing possible reasons for the student's partial success.

d. (Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the plan of care. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the plan of care since the student has not met her targeted outcome. The student may need more than time to reach her outcome, which makes (c) the wrong response.)

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes the theory of which theorist? A. Travelbee B. Watson C. Benner D. Swanson

d. (Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility. Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) write that caring is a basic way of being in the world and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted.)

A nurse is writing an evaluative statement for a patient who is trying to lower her cholesterol through diet and exercise. Which evaluative statement is written correctly? A. "Outcome not met." B. "1/21/15—Patient reports no change in diet." C. "Outcome not met. Patient reports no change in diet or activity level." D. "1/21/15—Outcome not met. Patient reports no change in diet or activity level."

d. (The evaluative statement must contain a date; the words "outcome met," "outcome partially met," or "outcome not met"; and the patient data or behaviors that support this decision. Answers a, b, and c are incomplete statements.)

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. What should the nurse do? A. Introduce oneself and thank the wife for being present. B. Introduce oneself and ask the wife if she wants to remain. C. Introduce oneself and ask the wife to leave. D. Introduce oneself and ask the patient if he would like the wife to stay.

d. (The patient has the right to indicate whom he would like to be present for the nursing history and exam. You should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife)

A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement below is not an example of a well-stated nursing intervention? A. Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. B. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. C. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake. D. Manage patient's pain.

d. (This statement lacks sufficient detail to effectively guide nursing intervention. The set of nursing interventions written to assist a patient to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what observations (assessments) need to be made and how often, what nursing interventions need to be done and when they must be done, and what teaching, counseling, and advocacy needs patients and families may have.)

What are the stages of Maslow's Hierarchy?

1. Physiological needs 2. Safety/security 3. love/belonging 4. Self-esteem 5. Self actualization

Which is a correctly written nursing diagnosis? 1. ineffective airway clearance r/t pneumonia 2. ineffective airway clearance r/t increased pulmonary secretions

2

Place the problems in order of highest priority to lowest priority based on Maslow's model. A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction

2, 4, 1, 3. (Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.)

After enough time has elapsed for the medication to take effect, you check back with the patient to evaluate whether he has obtained relief and met his outcome. If the patient is satisfied and you both feel that comfort is no longer a problem, you terminate the plan of care for this diagnosis. If the patient still feels pain or is dissatisfied with the medication, each of the preceding steps of the nursing process is re-evaluated, and necessary changes are made in the plan of care. What step in the nursing process is this?

Evaluate

The last step in the nursing process determines extent to which expected outcomes have been achieved. What is it called?

Evaluation

We should be using a 2 part statement when we write a nursing diagnosis. This will consist of :

problem & etiology

Why is the physical exam conducted after the patient interview?

so that data obtained in the interview can be verified

What does SMART stand for? What does this refer to?

specific, measurable, attainable, realistic, time bound outcome criteria for the planning step (pg 284)

The nursing process has several purposes. These are

*to identify helth care needs *determine priority of care *establish goals and develop expected outcomes *establish and communicate a client centered plan of care *provide nursing interventions to meet client needs *evaluate the effectiveness of nursing care

Direct care interventions

*ADL *instrumental ADL *physical care techniques *lifesaving measures *counseling *teaching *controlling for adverse reactions *Preventative Measures

Activities involved in Implementation stage

*Carry out the plan of care. *Continue data collection, and modify the plan of care as needed. *Document care.

A nurse uses the following classic elements of evaluation when caring for patients. Place them in their correct sequence. (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting one's judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what one is looking for when evaluating, e.g., expected patient outcomes)

5, 2, 1, 3, 4 (The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards (what you are looking for when you evaluate, e.g., expected patient outcomes), (2) collecting data to determine whether these criteria and standards are met, (3) interpreting and summarizing findings, (4) documenting your judgment, and (5) terminating, continuing, or modifying the plan.)

T/F There must be a general plan of action that covers all the nursing diagnoses.

False (There must be a plan for EACH nursing diagnosis)

What is the difference between a medical diagnosis and a nursing diagnosis?

Nursing diagnoses focus on the client while a medical diagnosis focuses on dx & tx of the disease

A school nurse notices that a female adolescent student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disorder. How should the nurse proceed? A. Perform the focused assessment. This is an independent nurse-initiated intervention. B. Request an order from Jill's physician since this is a physician-initiated intervention. C. Request an order from Jill's physician since this is a collaborative intervention. D. Request an order from the nutritionist since this is a collaborative intervention.

a. (Performing a focused assessment is an independent nurse-initiated intervention, thus the nurse does not need an order from the physician or the nutritionist.)

Types of nursing diagnoses

actual risk (potential) possible wellness (health promotion)

Sources of Assessment data

client (primary) family/partner other health professionals medical records other records/technology literature review nurse's experience

What do we chart in the evaluation step?

client's response to intervention, intervention effectiveness, whether the goal has been met (and date), any revisions of care plans needed

Remember! _____________ is proof that you have actually done something.

documentation

Which step of the nursing process puts the plan into action?

implementation

A statement that describes a clinical judgement of a client's actual or potential response to a health problem that is in the nurse's domain

nursing diagnosis (domain: something we are licensed to do)

A systematic approach to problem solving that allows the nurse to identify, dx and treat human response to health & illness

nursing process

Activities involved in Diagnosing a client

*Interpret and analyze patient data. *Identify patient strengths and health problems. *Formulate and validate nursing diagnoses. *Develop prioritized list of nursing diagnoses.

Read the following scenario and identify the term for the characteristics of patient data that are numbered below. Place your answers on the lines provided. The nurse is conducting an initial assessment of a 79-year old female patient admitted to the hospital with a diagnosis of dehydration. The nurse: (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data, (2) first asks the patient about the most important details leading up to her diagnosis, (3) collects as much information as possible to understand the patient's health problems, (4) collects the patient data in an organized manner, (5) verifies that the data obtained is pertinent to the patient care plan, and (6) records the data according to agency policy.

(1) Purposeful: The nurse identifies the purpose of the nursing assessment (comprehensive) and gathers the appropriate data. (2) Prioritized: The nurse gets the most important information first. (3) Complete: The nurse gathers as much data as possible to understand the patient health problem and develop a plan of care. (4) Systematic: The nurse gathers the information in an organized manner. (5) Factual and accurate: The nurse verifies that the information is reliable. (6) Recorded in a standard manner: The nurse records the data according to agency policy so that all caregivers can easily access what is learned.

The steps in the nursing process are:

*Assessment (establishes database on client) *Diagnose (identify actual/potential problems) *Plan (putting priorities, outcomes, etc into a plan) *Implement (putting plan into action) *Evaluate (look at each intervention &effectiveness of entire plan)

What are the steps in Assessment?

*Collect data (client interview, hx, physical exam, lab data) *Analyze data (verify/validate data, data clusters, document data) *Communicate data (all data should be accurate, complete, concise, factual, and recorded in timely manner)

Activities involved in the Planning phase

*Establish priorities. *Write outcomes and develop an evaluative strategy. *Select nursing interventions. *Communicate plan of nursing care.

Activities involved in Evaluation

*Measure how well the patient has achieved desired outcomes. *Identify factors that contribute to the patient's success or failure. *Modify the plan of care (if indicated)

Indirect care interventions

*communicating nursing interventions *delegating, supervising, evaluating work of other staff

You are checking on a patient who had abdominal surgery yesterday and hear that the patient has considerable pain: "It kept me up all night." The patient has been reluctant to ask for any pain medication, fearing effects of the drug. "I don't want to become a junkie." The patient's blood pressure and pulse rate are slightly elevated. What step in the nursing process is this?

Assessment

What skills do the Implementation step of the nursing process involve?

Cognitive, interpersonal, psychomotor, ethical/legal

Which of the following is subjective data? A. O2 sat down to 89% during activity B. B/P 150/100 C. O2 via nasal cannula @ 2L/min D. c/o fatigue and weakness

D

Define an etiology statement

Identifies the factors that are maintaining the unhealthy state or response (contributing or causative factors)

You decide to work with the patient to achieve the outcome: By 3:00 pm, patient reports sufficient relief of pain to enable him to rest and to get out of bed to go to the bathroom. The patient wants to accomplish the outcome. You identify teaching as the primary nursing intervention. What step in the nursing process is this?

Plan

Which step in the nursing process has a purpose of establishing goals, expected outcomes, determining priority of care, and to design nursing strategies to accomplish outcomes?

Planning

A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake." This is an example of what type of outcome? A. Cognitive B. Psychomotor C. Affective D. Physical changes

a (Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; affective outcomes pertain to changes in patient values, beliefs, and attitudes; and physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).)

A quality-assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, "We'd better find the folks responsible for these errors and see if we can replace them." This is an example of: A. Quality by inspection B. Quality by punishment C. Quality by surveillance D. Quality by opportunity

a (Quality by inspection focuses on finding deficient workers and removing them. Quality as opportunity (d) focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Answers b and c are distractors.)

The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions are examples of subjective data? Select all that apply. A. A patient tells the nurse that she is feeling nauseous. B. A patient's ankles are swollen. C. A patient tells the nurse that she is nervous about her test results. D. A patient complains of having a rash on her arm that is itchy. E. A patient rates his pain as a 7 on a scale of 1 to 10. F. A patient vomits after eating supper.

a, c, d, e (Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, itchy, or chilly and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elevated temperature reading (e.g., 101°F), edema, and vomiting.)

Which of the following are examples of nursing diagnoses? Select all that apply. A. Impaired Gas Exchange B. Renal Failure C. Excessive Fluid Volume D. Caregiver Role Strain E. Shortness of breath F.Ineffective Coping

a, c, d, f

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: A. Quality assurance B. Quality improvement C. Process evaluation D. Outcome evaluation

b (Unlike quality assurance, quality improvement is internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than individuals, and has no end points. Its goal is improving quality rather than assuring quality. Answers c and d are types of quality-assurance programs.)

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? A. Systematic B. Interpersonal C. Dynamic D. Universally applicable in nursing situations

b (interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process.)

A nurse is planning care for a male adolescent patient who is admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. A. The nurse formulates nursing diagnoses. B. The nurse identifies expected patient outcomes. C. The nurse selects evidence-based nursing interventions. D. The nurse explains the nursing care plan to the patient. E. The nurse assesses the patient's mental status. F. The nurse evaluates the patient's outcome achievement.

b, c, d. (During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the plan of nursing care. Although all these steps may overlap, formulating and validating nursing diagnoses occurs most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.)

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: A. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice B. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice C. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice D. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

c (evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.)

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. A. A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. B. A nurse consults with a psychiatrist for a patient who abuses pain killers. C. A nurse checks the skin of bedridden patients for skin breakdown. D. A nurse orders a kosher meal for an orthodox Jewish patient. E. A nurse records the I&O of a patient as prescribed by his physician. F. A nurse prepares a patient for minor surgery according to facility protocol.

c, d, f. (Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a physician. Consulting with a psychiatrist is a collaborative intervention.)

Critical thinking has several competencies. These are:

cognitive, technical, interpersonal, ethical/legal

A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? A. The nurse collects data to identify health problems. B. The nurse collects data to identify patient strengths. C. The nurse collects data to justify terminating the plan of care. D. The nurse collects data to measure outcome achievement.

d (The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the plan of care, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.)