n113 nursing process [end of chapter 11-15 questions]

5. 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).

1. 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. (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.

1. 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.

1. 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.

2. 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

2. 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.

8. 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? a Actual b Risk c Possible d 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.

3. 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.

3. 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.

4. 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 Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? a 2, 4, 1, 3 b 3, 1, 4, 2 c 2, 4, 3, 1 d 3, 2, 4, 1

4. a. 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.

4. 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.

4. 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.

5. 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."

5. 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.

6. 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.

6. 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.

7. 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.

7. 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.

8. 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

8. 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.

7. The nurse recognizes which of the following as a benefit of using a standardized care plan? 1. No individualization is needed. 2. The nurse chooses from a list of interventions. 3. They are much shorter than nurse-authored care plans. 4. They have been approved by accrediting agencies.

Answer: 2. Rationale: Standardized care plans provide a list of interventions from which the nurse can choose. The plan must still be individualized (option 1). Standardized plans could be longer or shorter than nurse-authored ones (option 3), but have not been approved by any outside accreditor (option 4).

9. When written properly, NOC outcomes and indicators 1. Do not require customization. 2. Address several nursing diagnoses. 3. Are broad statements of desired end points. 4. Reflect both the nurse's and the client's values.

Answer: 4. Rationale: NOC outcomes should reflect both the nurse's and the client's values of what is trying to be achieved. The outcomes still must be customized (option 1), but address only one nursing diagnosis at a time (option 2). Outcomes are narrow/specific end points, not broad (option 3).

8. Which of the following would indicate a significant cue when comparing data to standards? Select all that apply. 1. The client has moved partway toward a set goal (e.g., weight loss). 2. The client's vision is within normal range only when wearing glasses. 3. A child is able to control bladder and bowels at age 18 months. 4. A recently widowed woman states she is "unable to cry." 5. A 16-year-old high school student reports spending 6 hours doing homework five nights per week.

Answer: 1, 4, and 5. Rationale: A client's movement toward a goal (option 1) or whose behavior is inconsistent with population norms (options 4 and 5) represents a cue that further analysis toward creating a nursing diagnosis is required. Corrected vision (option 2) and bladder and bowel control at age 18 months (option 3) are consistent with population norms.

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

Answer: 1, 4, and 5. Rationale: Nurses should always have clear rationales for their actions, clients should be given options whenever possible, and client teaching is a constant, integral part of implementing. Primary care provider orders must be critically evaluated and modified to meet individual client needs (option 2). Clients may have nurses provide needed care but should take care of themselves whenever possible since dependency has its own complications (option 3).

5. A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis 1. If both medical and nursing interventions are required to treat the problem. 2. When independent nursing actions can be utilized to treat the problem. 3. In cases where nursing interventions are the primary actions required to treat the problem. 4. When no medical diagnosis (disease) can be determined

Answer: 1. Rationale: A collaborative (multidisciplinary) problem is indicated when both medical and nursing interventions are needed to prevent or treat the problem. If nursing care alone (whether that care involves independent or dependent nursing actions) can treat the problem, a nursing diagnosis is indicated. If medical care alone can treat the problem, a medical diagnosis is indicated

6. In the case in which a client is vulnerable to developing a health problem, the nurse chooses which type of nursing diagnosis status? 1. A risk nursing diagnosis 2. A syndrome nursing diagnosis 3. A health promotion nursing diagnosis 4. An actual nursing diagnosis

Answer: 1. Rationale: A risk nursing diagnosis is appropriate when the evidence for the problem indicates that a condition exists that makes the client vulnerable to a problem. A syndrome diagnosis is assigned by a nurse's clinical judgment to describe a cluster of nursing diagnoses that have similar interventions (option 2). Health promotion diagnoses are used when the client seeks to increase well-being but need not currently be well (option 3). An actual diagnosis is used when the client already exhibits the problem (option 4). Cognitive Level: Remembering. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 12-1.

6. Which of the following is the purpose of assessing? 1. Establish a database of client responses to his or her health status. 2. Identify client strengths and problems. 3. Develop an individualized plan of care. 4. Implement care, prevent illness, and promote wellness.

Answer: 1. Rationale: Assessing provides a database of the client's physiological and psychosocial responses to his or her health status. Client strengths and problems (option 2) are identified in the diagnosing phase of the nursing process, a care plan is established (option 3) in the planning phase, and care, prevention, and wellness promotion (option 4) are part of the implementing phase. Cognitive Level: Remembering. Client Need: N/A. Nursing Process: Assessment. Learning Outcome: 11-3

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

Answer: 1. Rationale: During implementing, the nurse also assesses and compares with the initial assessment. Evaluating follows implementing (option 2), mobilization of other health care teams is a part of implementing (option 3), and evaluating occurs during or immediately after each intervention, not waiting for all interventions to be completed (option 4).

8. Which of the following is likely to occur if a goal statement is poorly written? 1. There is no standard against which to compare outcomes. 2. The nursing diagnoses cannot be prioritized. 3. Only dependent nursing interventions can be used. 4. It is difficult to determine which nursing interventions can be delegated

Answer: 1. Rationale: Goal statements provide the standard against which outcomes are measured. Nursing diagnoses are prioritized before goals are written (option 2). Both independent and dependent interventions may be appropriate for any goal (option 3). Clarity the goal does not influence delegation of the intervention (option 4).

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

Answer: 4. Rationale: Quality improvement (QI) plans corrective actions for problems. QI focuses on process rather than outcomes (option 1), client care rather than structure (option 2), and aims for improvement rather than confirmation of quality (option 3).

1. Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process? 1. Identifying major problems or needs 2. Organizing data in the client's family history 3. Establishing short-term and long-term goals 4. Administering an antibiotic brunner end of chapter 11 questions

Answer: 1. Rationale: Identifying problems/needs is part of a nursing diagnosis. For example, a client with difficulty breathing would have Impaired Gas Exchange related to constricted airways as manifested by shortness of breath (dyspnea) as a nursing diagnosis. Organizing the family history is part of the assessment phase. Establishing goals is part of the planning phase. Administering an antibiotic is part of the implementation phase. Cognitive Level: Applying. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 11-1.

10. Which of the following principles does the nurse use in selecting interventions for the care plan? 1. Actions should address the etiology of the nursing diagnosis. 2. Always select independent interventions when possible. 3. There is one best intervention for each goal/outcome. 4. Interventions should be "doing," not just "monitoring."

Answer: 1. Rationale: Interventions should address the etiology of the nursing diagnosis. Both independent and dependent interventions should be selected if appropriate (option 2) and several interventions may be needed for a single outcome (option 3). Both action and assessment-type interventions can be used (option 4).

2. The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following? 1. Hospital policies 2. Standardized care plans 3. Orthopedic protocols 4. Standards of care

Answer: 1. Rationale: Policy and procedure documents provide data about how certain situations are handled. Standardized care plans (option 2) and standards of care (option 4) are written for groups of clients with similar medical or nursing diagnoses. They generally do not address questions such as hospital routines and nonmedical client needs. Note: Even hospital policies are not absolute. Each situation must be analyzed and responded to individually. Orthopedic protocols (option 3) would address elements specifically associated with the surgery, not whether the family slept in the room. Cognitive Level: Applying.

3. Which of the following nursing diagnoses contains the proper components? 1. Risk for Caregiver Role Strain related to unpredictable illness course 2. Risk for Falls related to tendency to collapse when having difficulty breathing 3. Impaired Communication related to stroke 4. Sleep Deprivation secondary to fatigue and a noisy environment

Answer: 1. Rationale: States the relationship between the stem (caregiver role strain) and the cause of the problem. Option 2: The diagnostic statement says the same thing as the related factor (falls and collapse). Option 3: It is inappropriate to use medical diagnoses such as stroke within a nursing diagnosis statement. Option 4 is vague. The statement must be specific and guide the plan of care (fatigue may be a result of sleep deprivation and does not direct intervention).

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

Answer: 1. Rationale: The desired outcomes and indicator statements reflect the parameters by which success will be measured. The goal can be met even if the nursing activities were not carried out or were ineffective (options 2 and 3). Although the desired outcome, by definition, indicates a change in the client's condition (behavior, knowledge, or attitude), only specific changes (desired outcomes) reflect the success of the care plan (option 4).

8. A major characteristic of the nursing process is which of the following? 1. A focus on client needs 2. Its static nature 3. An emphasis on physiology and illness 4. Its exclusive use by and with nurses

Answer: 1. Rationale: The nursing process focuses on client needs. It is dynamic rather than static (option 2), emphasizes client responses rather than physiology and illness (option 3), and is collaborative rather than used exclusively by nurses (option 4). Cognitive Level: Understanding.

10. Which of the following represent effective planning of the interview setting? Select all that apply. 1. Keep the lighting dimmed so as not to stress the client's eyes. 2. Ensure that no one can overhear the interview conversation. 3. Stand near the client's head while he or she is in the bed or chair. 4. Keep approximately 3 feet from the client during the interview. 5. Use a standard form to be sure all relevant data are covered in the interview.

Answer: 2, 4, and 5. Rationale: The nurse plans the interview so that privacy is observed. A comfortable distance between nurse and client to respect the client's personal space is about 3 feet. Using a standard form will help ensure the nurse doesn't omit gathering any vital information. Lighting should be at a normal level—neither bright nor dim (option 1). The nurse should be at the same height as the client, usually sitting, at approximately a 45° angle facing the client. The nurse standing over the client creates an uncomfortable atmosphere for an interview (option 3).

2. In the diagnostic statement "Excess Fluid Volume related to decreased venous return as manifested by lower extremity edema (swelling)," the etiology of the problem is which of the following? 1. Excess fluid volume 2. Decreased venous return 3. Edema 4. Unknown

Answer: 2. Rationale: Because the venous return is impaired, fluid is static, resulting in swelling. Therefore, decreased venous return is the cause (etiology) of the problem. Excess Fluid Volume is the nursing diagnosis, and edema of the lower extremity is the sign/symptom or critical attribute. The cause is known.

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

Answer: 2. Rationale: Because this assessment focuses on how care is provided, it is a process evaluation. A structure evaluation (option 1) would focus on the setting (e.g., how well equipment functions), and outcome evaluations (option 3) focus on changes in client status (e.g., whether reported satisfaction levels vary with type of person who answers the call light). An audit (option 4) would be a chart or document review.

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

Answer: 2. Rationale: Evaluating requires that client behavior be compared to expected outcomes. Goals may be partially met in addition to completely met or unmet (option 1). An outcome may be achieved but not be a direct result of the plan or interventions (option 3). A care plan should be continued, modified, or terminated based on achievement of outcomes (option 4).

1. The nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement? 1. Assess the client's needs. 2. Delineate the client's problems and strengths. 3. Determine which interventions are most likely to succeed. 4. Estimate the cost of several different approaches. brunner ch 12 end of chapter

Answer: 2. Rationale: In diagnosing, data from assessment (option 1) are analyzed and problems, risks, and strengths are identified before diagnostic statements can be established. Interventions (option 3) are more commonly part of the planning and implementing phases of the nursing process. Cost (option 4) is an important consideration but would be estimated in the planning phase. Cognitive Level: Applying. Client Need: N/A. Nursing Process: Diagnosis. Learning Outcome: 12-4.

3. The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The client's pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but skin is very dry. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan? 1. Pain 2. Nausea 3. Constipation 4. Potential for wound infection

Answer: 2. Rationale: More detailed assessment data and consultation with the client would be needed to absolutely confirm the priority. Postoperative nausea to the level of inhibiting oral intake has the greatest likelihood of leading to complications and requires nursing intervention now. The client's pain level is not extreme considering the recency of the surgery, and pain intervention can be assumed to be effective (option 1). Although the constipation is probably bordering on abnormal, a nursing intervention would most likely begin with oral treatment, which is not possible due to the nausea. More invasive interventions such as an enema or suppository would not be commonly administered the first day postoperative (option 3). Wound infection can occur, but there are no data to indicate that this requires a change in the current plan (option 4)

3. Which of the following elements is best categorized as secondary subjective data? 1. The nurse measures a weight loss of 10 pounds since the last clinic visit. 2. Spouse states the client has lost all appetite. 3. The nurse palpates edema in lower extremities. 4. Client states severe pain when walking up stairs.

Answer: 2. Rationale: Primary data come from the client (option 4), whereas secondary data come from any other source (chart, family). Subjective data are covert (reported or an opinion), whereas objective data can be measured or validated (weight—option 1, edema—option 3). If the spouse had stated that the client had eaten only toast and tea, this would be secondary objective (measured) data. Cognitive Level: Applying.

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

Answer: 2. Rationale: There is no reason to delete (option 1) or modify (option 3) the nursing diagnosis or demote its priority (option 4) because the risk factors that prompted it are still present.

6. 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.

6. Place the following activities of planning in the correct order of their use. 1. Establish goals/outcomes. 2. Write the care plan. 3. Set priorities. 4. Choose interventions.

Answer: 3, 1, 4, and 2. Rationale: In planning, first the nurse sets priorities and then writes goals/outcomes, selects interventions, and then writes the nursing care plan.

5. The care plan includes a nursing intervention "4/2/15 Measure client's fluid intake and output. F. Jenkins, RN." What element of a proper nursing intervention has been omitted? 1. Action verb 2. Content 3. Time 4. None

Answer: 3. Rationale: Although there may be standard policies or routines for measuring intake and output, the nursing intervention should specify if this is to be done "routinely" or at specific intervals (e.g., q4h). The nurse is also aware, however, that critical thinking indicates that the intake and output should be monitored more frequently than ordered if assessment reveals abnormal findings.

7. Which of the following is true regarding the state of the science in regards to nursing diagnosis? 1. The original taxonomy has proven to be adequate in scope. 2. The organizing framework of the taxonomy is based on the work of Florence Nightingale. 3. More research is needed to validate and refine the diagnostic labels. 4. New diagnostic labels are approved by means of a vote of registered nurses.

Answer: 3. Rationale: Diagnostic labels are continuously reviewed and revised as indicated by research—much more of which is needed. The original taxonomy has been replaced by Taxonomy II and is no longer based on a nurse theorist (options 1 and 2). New diagnoses are approved by NANDA International's Diagnostic Review Committee, not by a vote of nurses (option 4).

2. Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care? 1. Proposes hypotheses. 2. Generates desired outcomes. 3. Reviews results of laboratory tests. 4. Documents care.

Answer: 3. Rationale: During assessment, data are collected, organized, validated, and documented. Hypotheses are generated during diagnosing; outcomes are set during planning; and documentation occurs throughout the nursing process.

4. The nurse wishes to determine the client's feelings about a recent diagnosis. Which interview question is most likely to elicit this information? 1. "What did the doctor tell you about your diagnosis?" 2. "Are you worried about how the diagnosis will affect you in the future?" 3. "Tell me about your reactions to the diagnosis." 4. "How is your family responding to the diagnosis?"

Answer: 3. Rationale: Eliciting feelings requires an open-ended question that does more than seek factual information (option 1) and cannot be answered with a single word (option 2). The family can provide indirect information about the client, but is not most likely to provide the most accurate information (option 4). Cognitive Level: Analyzing. Client Need: N/A. Nursing Process: Assessment. Learning Outcome: 11-8.

7. In the validating activity of the assessing phase of the nursing process, the nurse performs which of the following? 1. Collects subjective data. 2. Applies a framework to the collected data. 3. Confirms data are complete and accurate. 4. Records data in the client record.

Answer: 3. Rationale: In validating, the nurse confirms that data is complete and accurate. Subjective data is collected in the collecting activity (option 1), a framework is applied to the data in the organizing activity (option 2), and data is recorded in the documenting activity (option 4).

4. The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly stated goal/ outcome? The client will 1. Turn in bed q2h. 2. Report the importance of applying lotion to skin daily. 3. Have intact skin during hospitalization. 4. Use a pressure-reducing mattress.

Answer: 3. Rationale: The goal or outcome should state the opposite of the nursing diagnosis stem, and thus healthy intact skin is the reverse condition of impaired skin integrity. Turning in bed, applying lotion, and using a special mattress are all interventions that may result in achieving the goal (options 1, 2, and 4).

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

Answer: 3. Rationale: This client needs psychosocial support rather than skills related to knowledge (options 1 and 2) or hands-on activity (option 4).

5. The use of a conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? 1. Correlation of the data with other members of the health care team 2. Demonstration of cost-effective care 3. Utilization of creativity and intuition in creating a plan of care 4. Collection of all necessary information for a thorough appraisal

Answer: 4. Rationale: Frameworks help the nurse be systematic in data collection. Other members of the health care team may use very different conceptual organizing frameworks so data may not correlate (option 1). Cost-effective care (option 2) is more likely to occur with systematic application of the nursing process, but use of a framework for assessment alone may not accomplish this goal. Because the framework is structured and because of the nature of client needs/problems, creativity and intuition in care planning are not assured (option 3).

9. Which of the following would be true regarding use of the observing method of data collection? 1. When observing, the nurse uses only the visual sense. 2. Observing is done only when no other nursing interventions are being performed at the same time. 3. Data should be gathered as it occurs, rather than in any particular order. 4. Observed data should be interpreted in relation to other sources of collected data.

Answer: 4. Rationale: Interpreting collected data is necessary to help validate its accuracy. Observing includes the senses of smell, hearing, and touch in addition to vision (option 1). Using priority setting, observing must often be performed simultaneously with other activities (option 2). A systematic approach to observing data helps ensure nothing is missed and the nurse pays attention to the most important data first (option 4)

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

Answer: 4. Rationale: It is never acceptable practice for the nurse to document a nursing activity before it is carried out. This would be very unsafe because many things can cause an activity to be postponed or canceled and prior charting would be inaccurate, misleading, and potentially dangerous. In a few situations, it may be permissible to chart frequent or routine activities some time following the activities such as at the end of a shift or after a particular interval (e.g., every 4 hours) rather than immediately following the activity. Cognitive Level: Applying.

1. After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit? 1. Initial 2. Ongoing 3. Discharge 4. Strategic end of ch 13 brunner

Answer: 4. Rationale: Strategic planning is an ongoing process focused on organizational change rather than individual clients so it is least useful and not relevant in this case. The client requires initial planning because he has just arrived on the orthopedic unit for the first time (option 1). Of the three types of planning that need to be done at this time, initial is the highest priority since he has just had surgery. The client also requires the ongoing type of planning necessary to determine the care appropriate for this shift (option 2). Discharge planning needs to start on admission to ensure adequate client preparation for management of health needs outside the health agency (option 3).

4. One of the primary advantages of using a three-part diagnostic statement such as the problem-etiology-signs/symptoms (PES) format includes which of the following? 1. Decreases the cost of health care. 2. Improves communication between nurse and client. 3. Helps the nurse focus on health and wellness elements. 4. Standardizes organization of client data.

Answer: 4. Rationale: The PES format assists with comprehensive and accurate organization of client data. More efficient planning may or may not reduce health care costs. Nursing diagnostic statements should be confirmed with the client but using PES does not ensure this. PES statements can be wellness or illness focused.

9. 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.

7. 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.

1. When initiating the implementation phase of the nursing process, the nurse performs which of the following phases first? 1. Carrying out nursing interventions 2. Determining the need for assistance 3. Reassessing the client 4. Documenting interventions ch 14 end of ch brunner

_3. Rationale_ The first step of implementing is reassessingthe client to determine that the activity is still indicated and safe. Thenext action would be to determine if assistance is required (option 2),then implement the intervention (delegating if appropriate) (option1), and last document the intervention (option 4). Cognitive Level_Understanding_

8. 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.

3. 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.

5. 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.

2. 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.

7. 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? a "Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue." b "Job well done . . . you've identified this problem early and we can manage it before it becomes more acute." c "Is this an actual or a possible diagnosis?" d "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.

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

7. 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.

6. 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).

1. 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.

9. 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.

10. 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.

1. 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.

9. 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.

2. 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. a Bronchial pneumonia b Impaired gas exchange c Ineffective airway clearance d Potential complication: sepsis e Infection related to pneumonia f 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.

2. 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.

1. 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. a The nurse uses the nursing interview to collect patient data. b The nurse analyzes data collected in the nursing assessment. c The nurse develops a care plan for the patient. d The nurse points out the patient's strengths. e The nurse assesses the patient's mental status. f 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.

10. 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.

3. 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.

8. 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."

10. 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.

3. 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? a No problem b Possible problem c Actual nursing diagnosis d 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.

4. 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? a Risk for Impaired Skin Integrity b Related to prescribed bedrest c As evidenced by d 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.

5. 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.

3. 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.

2. A nurse uses the following classic elements of evaluation when caring for patients. Which item below places 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) a 1, 2, 3, 4, 5 b 3, 2, 1, 4, 5 c 5, 2, 1, 3, 4 d 2, 3, 1, 4, 5

c. 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.

9. 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.

4. 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.

8. 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.

4. 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.

6. 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.

10. 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. e 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.

9. 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 a (1) and (2) b (3) and (4) c (1), (2), and (3) d 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.

5. 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? a Collaborative problem b Interdisciplinary problem c Medical problem d 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.

7. 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.

10. 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.