Ch. 16
A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?
"Client will identify one coping strategy to try by end of week."
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?
"I will test my glucose level before meals and use sliding scale insulin."
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?
"Please tell me your thoughts about treating this diagnosis."
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 standardized care plan
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?
Add the nursing diagnosis: Risk for Self-Harm.
The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply.
After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn. By 4/5/20, the client will demonstrate how to care for a colostomy. After counseling, the client will describe two coping measures to deal with stress.
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?
Client is normotensive.
Which is an appropriate expected outcome for a client?
Client will ambulate safely with walker in the room within 3 days of physical therapy.
A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?
Client will have formed stools within 24 hours.
The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome?
Client will maintain nutritional intake without pain or diarrhea.
Which guideline should the nurse follow when including interventions in a plan of care?
Date the nursing interventions when written and when the plan of care is reviewed.
A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?
Developing the plan without client input
A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?
Educational
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?
Encourage hourly use of the incentive spirometer.
A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?
Individualize the plan to the client.
Which provides the best framework for prioritizing client problems?
Maslow's hierarchy of needs
Which are characteristics of appropriate client outcome statements? Select all that apply.
Measurable Realistic Specific
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?
Narcotic analgesic to treat pain
Which statement correctly describes a nurse-initiated intervention?
Nurse-initiated interventions are derived from the nursing diagnosis.
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?
Nurses do carry out interventions in response to a physician's order.
A computerized information system developed to classify client outcomes is the:
Nursing Outcome Classification system
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?
On the client's admission to the hospital
A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?
Ongoing
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?
Outcome
What are specific measurable and realistic statements of goal attainment?
Outcomes
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?
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?
Perform hourly neurovascular assessment.
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
Psychomotor
A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest, and the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as?
Rationale
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?
Seek research about the disorder.
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?
Standardized
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?
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?
Supportive
Which is an example of a nurse-initiated intervention?
Teach the client how to splint an abdominal incision when coughing and deep breathing.
The nurse recognizes that an example of a cognitive outcome is:
The client identifies three foods high in potassium by August 8.
Which outcome for a client with a new colostomy is written correctly?
The client will demonstrate proper care of the stoma by 3/29/20.
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?
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?
The client will understand the effects of smoking related to heart disease.
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?
The nurse has omitted the time frame.
A client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a nonblanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take?
The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour.
A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?
Updating the diet orders in the client's plan of care
Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent?
Verb (action)
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:
condition.
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
discharge planning.
The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually
does not contain documented scientific rationales.
When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:
identifies factors causing undesirable response and preventing desired change.
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:
intervention.
The nurse recognizes that identifying outcomes/goals must include:
involvement of the client and family.
According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is:
physiological.
