Foundations Exam 2 Chapter 16 PrepU

The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) 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 should call my health care provider if I have a sore that won't heal." "I will take my medications on an empty stomach for maximum effect." "I will take the medications until the inflammation goes away." "I should increase water intake if I have dark bowel movements."

"I should call my health care provider if I have a sore that won't heal."

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

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

The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care? An 18-year-old woman sitting up in bed with an egg-size hematoma and a 5cm laceration on her forehead who is talking rapidly on her cell phone A 45-year-old man with burns to his upper arms and chest and soot on his face who is restless and anxious A 68-year-old woman with bruises across her chest and lower abdomen who is observed rubbing the bruised area on her lower abdomen and moaning A 4-year-old with a deformed left lower leg with equal pedal pulses in both feet and who is crying loudly

A 45-year-old man with burns to his upper arms and chest and soot on his face who is restless and anxious

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 An algorithm Guidelines An order set

A standardized care plan

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

Educational

A client is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes? Family Physical therapists Occupational therapists Pharmacists

Family

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

Nurse-initiated interventions are derived from the nursing diagnosis.

A nurse is preparing an in-service program for a group of staff nurses who are returning to the workforce. As part of the in-service, the nurse will be describing the different types of client plans of care. Which element would the nurse include as common to any type of plan of care? Select all that apply. Supportive assessment data Client goals Nursing diagnoses Nursing interventions Medical diagnoses

Nursing diagnoses Nursing interventions Client goals

A nurse is applying the nursing process and is involved in establishing priorities. The nurse is most likely in which phase of the nursing process? Diagnosis Outcome identification and planning Assessment Implementation

Outcome identification and planning

A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this client? The client will become mobile within a 24-hour period. Offer to help the client walk the length of the hallway each day. The nurse will help the client ambulate the length of the hallway once a day. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

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

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

Seek research about the disorder.

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

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

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 her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client? Once she is admitted to the nursing unit from postanesthetic recovery As soon as possible after her surgery Upon her admission to the hospital Once she has received a discharge order

Upon her admission to the hospital

The nurse is developing a plan of care for a newly admitted client to the nursing unit. The nurse knows that which elements are important to include in this plan of care? Select all that apply. allowing for involvement of support people providing standardized care planning care that is realistic and measurable promoting client participation

allowing for involvement of support people planning care that is realistic and measurable promoting client participation

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client and family's ability to cope. What action should the nurse take with this client? comforting the client and family asking the client if anyone in the family also has diabetes testing the client's glucose levels providing more information about diabetes

comforting the client and family

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

intervention.

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

involvement of client and family

A nurse is planning nursing interventions for patients on a busy hospital ward. Which guideline would the nurse follow when designing the plan of care? Date the nursing interventions when written and when the plan of care is reviewed. Make sure the nursing interventions are a separate entity from the original goal/ outcomes. Make sure the nursing intervention does not describe the nursing action to be performed. Make sure the nursing interventions are approved of and signed by the attending physician.

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

Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan? Discharge Ongoing Initial Standardized

Standardized

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2015." Why is this outcome inadequate? The outcome is not related to an independent nursing action. The outcome does not specify the conditions in which it will be achieved. The outcome is not observable or measurable. The statement expresses a client outcome as a nursing intervention.

The outcome is not related to an independent nursing action.

A nurse administers clonidine according to the standardized plan of care for a client admitted with hypertension. Which assessment information deviates from the expected client outcome for the first 24 hours and requires nursing intervention? BP is lower than admission Client walking gait is steady No reports of pain or headache Client gains 1 kg (2.2 lb) in 1 day

Client gains 1kg (2.2 lb) in 1 day

Which nursing diagnosis is the priority? Anxiety Spiritual distress Ineffective breathing patterns Stress incontinence

Ineffective breathing patterns

The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly? Explain to Mr. Conner the proper care of the stoma by 3/29/15. Mr. Conner will know how to care for his stoma by 3/29/15. Mr. Conner will demonstrate proper care of stoma by 3/29/15. Mr. Conner will be able to care for stoma and cope with psychological loss by 3/29/15

Mr. Conner will demonstrate proper care of stoma by 3/29/15.

A 56-year-old woman on the inpatient unit is 2 hours s/p gallbladder surgery. She is just waking up from anesthesia, and asks the nurse how long it will take until she can go home. The nurse responds that most clients are discharged within 2 days. The nurse's answer is most likely based on which piece of information? The individualized plan of care The client outcomes and interventions The scientific rationale The agency's critical path

The scientific rationale

A nurse is working with a newly admitted client with diabetes to develop client outcomes. When writing these outcomes, which verb would be appropriate to use in the statement. Select all that apply. Know Explain Understand State Demonstrate

Understand Demonstrate

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 identify foods that trigger uncomfortable symptoms. Client will talk with campus cafeteria manager about identifying safe meals. Client will maintain nutritional intake without pain or diarrhea. Client will learn to cook foods that meet personal nutritional needs.

client will maintain nutritional intake without pain or diarrhea.

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged 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 beginning the plan without family to help failing to update the written plan of care choosing actions that do not solve the problem

developing the plan without client input

A nurse is using the Nursing Outcome Classification system to assist in planning a client's care. The nurse understands that each outcome includes which component? Select all that apply. Definition Time frames Behaviors Measurement scale Indicators

Definition Measurement scale Indicators

The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the best indicator that the outcome expectations have been met? "I walk daily wearing low-heeled shoes." "I turn on lights at night so I won't fall." "I take extra calcium to make my bones stronger." "I removed scatter rugs from my home."

"I walk daily wearing low-heeled shoes."

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

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

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 lipids are within range. Client is normal tensive. Client reports no headache. Client is drowsy after lunch.

Client is normal tensive.

The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply. Client will report pain is controlled at or below 3 of 10. Client will maintain oxygen saturation at 81%. Client will perform dressing change independently. Client will receive influenza vaccine. Client will increase nutrition, eating 75% of meals.

Client will report pain is controlled at or below 3 of 10. Client will increase nutrition, eating 75% of meals. Client will perform dressing change independently.

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: Identifies the unhealthy response preventing desired change Identifies patient strengths Suggests patient goals to promote desired change Identifies factors causing undesirable response and preventing desired change

Identifies factors causing undesirable response and preventing desired change

After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care? It provides the client with information about treatments. It creates a teaching log for family. It verifies staffing. It helps deliver holistic, goal-oriented, individualized care.

It helps deliver holistic, goal-oriented, individualized care.

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

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

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning? Outcome planning Ongoing planning Initial planning Discharge planning

Ongoing planning

A nurse is reviewing the plan of care for a client and notes the following: "The client verbalizes three signs of hypoglycemia to the staff accurately before discharge." The nurse interprets this statement as a(n): Client outcome Outcome criteria Intervention Nursing Diagnosis

Outcome criteria

A nurse is caring for a 48-year-old man 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? Structure evaluation Outcome evaluation Cost-effectiveness evaluation Process evaluation

Outcome evaluation

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. Elevate the injured arm on a pillow. Give prescribed pain meds. Apply ice to the casted extremity.

Perform hourly neurovascular assessment.

Which of the following is a correctly written nursing intervention? Select all that apply. Provide opportunities for the client to express concerns and verbalize feelings. Understand the side effects of furosemide. Provide 5 to 6 small meals daily. Reposition the client from side to side every hour around the clock.

Provide 5 to 6 small meals daily. Reposition the client from side to side every hour around the clock. Provide opportunities for the client to express concerns and verbalize feelings.

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

Psychomotor

A nurse is working with a client who is having a difficult time accepting her new diagnosis of type II diabetes. The nurse pulls up a chair next to the client's bed and holds her hand while listening to her story. What type of nursing intervention is the nurse engaging in? Supervisory intervention Supportive intervention Psychosocial intervention Coordinating intervention

Supportive intervention

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention? Administer a 1000 ml soap suds enema. Administer morphine sulfate 2 mg IV push every 3 hours as needed for pain. Administer oxygen 4 L/min per nasal cannula. Teach client how to splint abdominal incision when coughing and deep breathing.

Teach client how to splint abdominal incision when coughing and deep breathing.

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 omitted the defining characteristics. The nurse has not made any error in writing the outcome. The outcome should indicate what the nurse will do. The nurse has omitted the time frame.

The nurse has omitted the time frame.

A father runs into the emergency room with his 18-month-old son in his arms. The father screams, "Help, he is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis? no priority medium priority high priority low priority

high priority

Which statement on a plan of care would a nurse identify as a nursing intervention? administers insulin correctly demonstrates deep-breathing exercises after education readiness for enhanced communication performs range of motion exercises to all joints each morning

performs range of motion exercises to all joints each morning

Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal? Assist the client to put on the clothing that goes over the operated leg. Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. Arrange for the social worker to schedule home health care with discharge planning. Tell the client's family to bring in clothes a size larger to make dressing easier.

Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.

The nurse is prioritizing the client's nursing diagnoses. Which nursing diagnosis has priority? Constipation related to decreased fluid intake and decreased mobility Self-care Deficit: Bathing related to joint inflammation Ineffective Airway Clearance related to retention of secretions Disturbed Sleep Pattern related to abdominal incisional pain

Ineffective Airway Clearance related to retention of secretions

The nurse, in collaboration with the client's family, is assigning priorities related to the care of the client. The nurse explains that when setting priorities it is important to look at the urgency of specific problems. What provides the best framework for prioritizing client problems? Nursing skill Availability of hospital resources Family member statements Maslow's hierarchy of needs

Maslow's hierarchy of needs

A nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The nurse then uses the data to update the client plan of care. What are these actions considered? Discharge planning Comprehensive planning Initial planning Ongoing planning

Ongoing planning

A client is on the surgical unit s/p resection of an intestinal tumor. She is alert and oriented x3. Based on assessment of the client, a medical order to "ambulate with assistance" is written in the chart. This will be the client's first time ambulating. Which best represents a nursing outcome? The client will ambulate with the assistance of a walker without falling within the next 4 hours. Physical therapy will be consulted to assist the client with ambulation. The client will ambulate with the assistance of a walker sometime today. The client will ambulate to the restroom 3 times this shift.

Physical therapy will be consulted to assist the client with ambulation.

Consider the following statement: "The client ambulated with the assistance of a cane without incident during his physical therapy session." Which part of the outcome criteria does the portion in italics represent? Criteria Who Condition Verb (action)

Verb (action)

A preceptor reviews the client outcomes written by a new nurse. Which outcome is the priority for the client with paranoid delusions? Within 2 days, client will perform personal hygiene without reminders. Within 3 days, client will mingle in the day room without violence. Client will verbalize side effects of antipsychotic medications within 24 hours. Client will discuss delusions in therapy sessions before discharge.

Within 3 days, client will mingle in the day room without violence.

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority? Within 48 hours, client will recognize when additional tranquilizers are needed. Client will discuss drinking habits in therapy sessions the day after admission. Client will take the first step of a 12-step program within 48 hours of admission. Within 3 days, client will be discharged.

Within 48 hours, client will recognize when additional tranquilizers are needed.

The nurse assigned to care for a client has established client outcomes and outcome criteria. After completing this task, what would the nurse do next? Identify objectives. Determine client goals. Establish priorities Write a client plan of care

Write a client plan of care

The nurse is writing a measurable outcome for a client with a new prosthesis to begin walking again. Which components must be included in the outcome? Select all that apply. the action the client will perform description in subjective terms of the expected client behavior particular circumstances in which the outcome is to be achieved modifiers describing the end result target time when the client is expected to be able to achieve the outcome the client or some part of the client

the action the client will perform particular circumstances in which the outcome is to be achieved the client or some part of the client target time when the client is expected to be able to achieve the outcome

The nurse is developing outcomes for the care plan of a client admitted with Parkinson's disease. The nurse will derive the outcomes for this client's care plan from: assessment data provided by the multidisciplinary team. assessment data gleaned from the physician's progress notes. the problem statement of the nursing diagnosis. the defining characteristics in the nursing diagnosis statement.

the problem statement of the nursing diagnosis

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client? to ambulate the client to a bedside chair to prevent repeat surgery in the client to help the client return to activities of daily life to maintain a healthy and active lifestyle

to ambulate the client to a bedside chair

A client is required to be n.p.o. 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? adding the diagnosis "altered nutrition, less than required" posting the sign "n.p.o. after midnight" over the bed obtaining written consent for the diagnostic procedure updating the diet orders in the client's plan of care

updating the diet orders in the client's plan of care