NURS 203 - Test 3

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns?

"Leaning forward may help you to breathe better."

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

"Client will identify one coping strategy to try by end of week."

For which client would a standardized plan of care most likely be appropriate?

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family?

A plan designed to support the client physically

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm.

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?

Altered Gas Exchange

Ongoing Planning

Carried out by any nurse who interacts with patient; keeps the plan to date; states nursing diagnoses more clearly; develops new diagnoses; makes outcomes more realistic and develops new outcomes as needed; identifies nursing interventions to accomplish patient goals

Discharge Planning

Carried out by the nurse who worked more closely with the patient; begins when the patient is admitted for treatment; uses teaching and counseling skills effectively to ensure home-care behaviors are performed competently

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normotensive.

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem?

Client will alternate rest periods with exercise throughout the day.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client?

Comfort the client and family.

Which guideline should the nurse follow when including interventions in a plan of care?

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

Initial planning

Developed by the nurse who performs the nursing history and physical assessment; addresses each problem listed in the prioritized nursing diagnoses; identifies appropriate patient goals and related nursing care

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

Developing the plan without client input

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse?

Encourage hourly use of the incentive spirometer.

Which actions should the nurse perform during the planning step of the nursing process? Select all that apply.

Establishing priorities Identifying expected client outcomes Selecting evidence-based nursing interventions Communicating the plan of nursing care

Describe 5 common problems related to planning, there possible causes, and remedies?

Failure to involve the patient,insufficient data collection,outcomes stated too broadly,nursing orders that do not solve problems,failure to update the care plan

Describe how patient goals/expected outcomes and nursing orders are derived from nursing diagnoses.

From the problem statement you get the goals, outcomes, objectives. Etiology we get our interventions. Patient goals/expected outcomes- nursing orders are derived from nursing Dx. Cognitive- describing increases in Pt knowledge or intellectual behaviors. Psycho motor - describes pts. achievements of new skills. Affective- describes changes in pt values, beliefs and attitudes.

These nursing diagnoses appear on a client's care plan. Place in the order in which the nurse will prioritize acting upon them. Use all options.

Impaired Swallowing Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client.

Identify the three elements of comprehensive planning.

Initial Planning Ongoing Planning Discharge Planning

What 3 helpful guides can one utilize to prioritize patient problems?

Maslow's Hierarchy of Needs Patient preferences Anticipated future problems

Which are characteristics of appropriate client outcome statements? Select all that apply.

Measurable Realistic Specific SMART Goals: Specific, Measurable, Attainable, Realistic, Timely

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

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

Which elements are common to any type of plan of care? Select all that apply.

Nursing diagnoses Client goals Nursing interventions

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

Ongoing

A nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

Outcome

What are specific measurable and realistic statements of goal attainment?

Outcomes

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client?

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

Which statement on a plan of care should a nurse identify as a nursing intervention?

Perform range-of-motion exercises to all of the client's joints each morning.

A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement?

Return the client to bed and provide pain relief measures.

What are short term and long term goals?

Short term goals-may be accomplished in a specific time period (Less than one week). Long term goals- requires a longer period (may be longer than a week) to be achieved and may be used as discharge goals.

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?

Standardized

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?

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

Which is an example of a nurse-initiated intervention?

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

The nurse recognizes that an example of a cognitive outcome is:

The client identifies three foods high in potassium by August 8.

Which outcome for a client with a new colostomy is written correctly?

The client will demonstrate proper care of the stoma by 3/29/20.

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision?

The client will understand the effects of smoking related to heart disease

When creating a care plan, which is the purpose of identifying the client outcome?

To design a plan of care to address the health problem

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?

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

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent?

Verb (action)

What verbs should the nurse use to write outcomes that are measurable? Select all that apply.

Verbalize Define

The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is:

a clinical pathway.

What is a nursing intervention?

any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes

What is clinical pathway (critical pathway, care map)?

case management tools used to communicate the standardized, interdisciplinary plan of care

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning.

Discuss patient preference

first meet the needs that the patient thinks are more important as long as this order does not interfere with other vital therapies

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

identifies factors causing undesirable response and preventing desired change.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention.

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

Discuss anticipation of future problems in nursing?

nurses must apply their knowledge base to consider the potential effects of different nursing actions. for example assigning a low priority to a diagnoses that the patient wants to ignore but can result in harmful future consequences

What is a Kardex care plan?

pertinent information about the patient

What is computerized plan of nursing care?

same as Kardex only computerized. Has drop downs.

Which actions occur during the initial planning of client care? Select all that apply.

-The nurse who performs the admission nursing history and physical assessment makes the initial plan. -After the initial plan is developed, the nurse prioritizes nursing diagnoses. -The nurse identifies client goals and the related nursing care in the initial plan.

Discuss Maslow's Hierarchy of Needs.

1. Physiological Needs - Includes the need for air , water, food , and sex 2. Security Needs - Includes the need for safety, order, and freedom from fear or threat 3. Affiliation Needs - Includes the need for love, affection, feelings of belonging, and human contact 4. Esteem Needs - Includes the need for self-respect, self-esteem, achievement, and respect from others 5. Self Actualization Needs - Includes the need to grow, to feel fulfilled, to realize one's potential Maintains that people have many needs, and they are continually striving to fulfill the needs they have not yet satisfied. The practical implications of this theory for motivation in organizations are many.

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem?

Client will not leave the premises without a caregiver.

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs?

Cutting up food and opening drink containers for the client

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 helps deliver holistic, goal-oriented, individualized care.

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client?

Narcotic analgesic to treat pain

Differentiate nurse initiated interventions, physician-initiated interventions, and collaborative interventions?

Nurse initiated intervention- actions performed by a nurse without physician order. Physician-initiated intervention-( you have to have physician order) action initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor's orders. Collaborative interventions- treatments initiated by other providers and carried out by a nurse.

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

On the client's admission to the hospital

A nurse is reviewing the plan of care for a client and notes: "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." The nurse should identify this statement as an example which element of nursing practice?

Outcome

Which phase of the nursing process most involves establishing priorities?

Outcome identification and planning

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

Psychomotor

Describe the purpose and benefits of outcome identification and planning.

Purpose: Design plan of care for and with patient that once implemented, results in prevention, reduction, or resolution of the patient's health problems and attainment of patient's health expectations, as identified in patient outcomes Benefits: 1. Individualized patient care 2. Continuity of care 3. Priorities set 4. Coordinate care 5. Promote nurse's professional development 6. Create record used for evaluation, reimbursement, and legal purposes 7. Facilitate communication

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

Which is an example of a psychomotor outcome?

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

What is consultation?

a process in which two or more people with varying degrees of experience and expertise discuss a problem and its solution

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition.

According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is:

physiological.

What is plan of nursing care (patient care plan)?

the written guide that directs the efforts of the nursing team working with patients to meet their health goals