Nursing Chapter 5
The nurse is caring for a patient diagnosed with Lyme disease. The patient tells the nurse, "My heart seems to be skipping some beats. My doctor told me to let the nurse know if this happens since it might be a complication of my disease." The nurse auscultates the heart and confirms the palpitations. Which step of the nursing process does the nurse's action demonstrate? a. Assessment b. Planning c. Implementation d. Evaluation
a. Assessment Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse identifies which statement to be a correctly written Nursing diagnosis appropriate for a patient's plan of care? a. Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds. b. Imbalanced nutrition: less than body requirements. c. Impaired physical mobility related to contractures. d. Risk for suffocation related to smoking in bed as evidenced by absent breath sounds.
a. Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds. Rationale: There are three types of diagnoses: actual, risk, and opportunities for improvement. Actual diagnoses have three parts: problem, etiology, and signs/symptoms. Risk diagnoses include only the identified need and the risk factors. The Nursing diagnosis, imbalanced nutrition: less than body requirements, is missing the problem, etiology, and signs and symptoms. Impaired physical mobility is missing the evidence. Risk for suffocation should have only two parts: the potential problem and etiology. There are no signs and symptoms if the patient is at risk.
A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process? a.Assessment b.Planning c.Implementation d.Evaluation
a.Assessment Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The nurse recognizes that the health history is conducted in which step of the nursing process? a.Assessment b.Diagnosis c.Implementation d.Evaluation
a.Assessment Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse is gathering data on a patient with acute bacterial pneumonia. The nurse recognizes that this is an example of which step of the nursing process? a.Assessment b.Planning c.Implementation d.Evaluation
a.Assessment Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse recognizes that establishing short- and long-term goals to address Nursing diagnoses involve which actions? (Select all that apply.) a.Discussion with the patient b.Exclusion of family with making patient decisions c.Collaboration with other members of health care team d.Making the health care provider as the central figure e.Coordination of care as collaborative care
a.Discussion with the patient c.Collaboration with other members of health care team e.Coordination of care as collaborative care Rationale: Establishing short- and long-term goals to address Nursing diagnoses involves discussion with the patient and often requires collaboration with family members and other members of the health care team. Coordinated, team-based patient care is called collaborative care. The patient's health care team members may include several nurses: the primary care provider; medical or surgical specialists; respiratory therapists; a dietitian; a physical therapist; occupational, music, or art therapists; a spiritual adviser; and social workers. The patient's primary nurse is often the central figure in coordinating collaborative care.
The nurse develops a list of Nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, "I understand that I will lose most of my hair. Will it grow back?" The nurse identifies which diagnosis will have the highest priority? a.Disturbed body image b.Nausea c.Risk for bleeding d.Imbalanced nutrition: less than body requirements
a.Disturbed body image Rationale: Priority of Nursing diagnoses is determined by the patient's preference as well as the severity of the symptoms. The patient is concerned about the loss of hair because this will affect body image. For the patient, this is a prime focus. It is possible that the patient may experience nausea as a result of the chemotherapy drugs. The patient will not be able to eat properly if the nausea is not controlled thus decreasing nutritional intake. There is a potential for bleeding as a result of the low platelet count created by the drugs. All of these must be addressed, but the primary diagnosis, in this case, would be body image.
he nurse is attempting to develop Nursing diagnoses for a patient. The nurse understands that Nursing diagnoses have which characteristics? (Select all that apply.) a.Nursing diagnoses identify actual or potential problems as well as responses to a problem. b.Nursing diagnoses require naming patient problems using Nursing diagnostic labels. c.Nursing diagnoses utilize objective data since subjective data are often inaccurate. d.Nursing diagnoses include unvalidated data to determine an accurate and thorough diagnosis. e.Nursing diagnoses are similar to medical diagnoses since they both are labels for diseases.
a.Nursing diagnoses identify actual or potential problems as well as responses to a problem. b.Nursing diagnoses require naming patient problems using Nursing diagnostic labels. Rationale: The nursing diagnosis identifies an actual potential problem or response to a problem. Accurate identification of of Nursing diagnoses for patients result from carefully analyzing, validating, and clustering related patient subjective (symptoms) and objective (signs) data. If data collection includes inaccurate or inadequate information or if data are not validated or clustered with related information, a patient may be misdiagnosed. Diagnosis in the nursing process requires naming patient problems using Nursing diagnostic labels. Medical diagnoses are labels for diseases, whereas Nursing diagnoses describe a response to an actual or potential problem or life process.
All nursing interventions that are implemented for patients must be documented or charted. The nurse knows that proper documentation of interventions leads to what positive outcome? a.Proper documentation facilitates communication with all members of the health care team. b.Proper documentation is only considered "legal" if documented in the paper chart. c.Proper documentation prevents errors of omission and repetition of care. d.Proper documentation does not directly measure goal achievement or outcomes.
a.Proper documentation facilitates communication with all members of the health care team. Rationale: All nursing interventions that are implemented for patients must be documented or charted. In some cases, this may involve checking off an intervention in the patient's EMR designed to track the effectiveness of specific interventions. Many health care agencies have special requirements for documenting interventions such as the use of physical restraints or pain protocols. Proper documentation of interventions facilitates communication with all members of the health care team and provides an essential legal record. Accurate charting helps to alleviate omissions and repetition of care although it cannot prevent them. Documentation also allows nurses to evaluate the effectiveness of nursing interventions in meeting patient goals and outcomes, which is the final step in the nursing process.
The nurse identifies the nursing process as the foundation of professional nursing practice and can define it in which appropriate terms? a.The framework that nurses use to provide care. b.A complex process during which nurses think about their thinking. c.The process that allows nurses to collect essential data. d.Thinking like a nurse in developing plans of care.
a.The framework that nurses use to provide care. Rationale: The nursing process is the foundation of professional nursing practice. It is the framework within which nurses provide care to patients in an organized and effective manner. Paul describes critical thinking as a complex process during which individuals think about their thinking to provide clarity and increase precision and relevance in a specific situation while attempting to be fair and consistent. Critical thinking using the nursing process allows nurses to collect essential patient data, articulate the specific needs of individual patients, and effectively communicate those needs, realistic goals, and customized interventions with members of the health care team. Thinking like a nurse is facilitated by nurses using the nursing process in the development of individualized patient plans of care.
The nurse knows which statements would be considered objective data? (Select all that apply.) a."I'm short of breath." b."Blood pressure 90/68, apical pulse 102, skin pale and moist." c."Lung sounds clear bilaterally, diminished in right lower lobe." d."I feel weak all over when I exert myself." e."My pain level is down to 2. It was 8."
b."Blood pressure 90/68, apical pulse 102, skin pale and moist." c."Lung sounds clear bilaterally, diminished in right lower lobe." Rationale: Data collected from medical records, laboratory, and diagnostic test results, or physical assessments are objective. Objective data (i.e., signs) consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested. Subjective data (i.e., symptoms) are spoken. Patients' feelings about a situation or comments about how they are feeling are examples of subjective data. Data shared by a source verbally are considered subjective. Subjective data may be difficult to validate because they cannot be independently and objectively measured.
7. The nursing student is caring for a patient admitted with severe anemia. The patient receives two units of packed red blood cells and tells the student, "I am feeling so much better. I'm not so tired anymore and can bathe myself." The student reviews the patient goal "report an increase in activity tolerance" and concludes that the patient's goal has been met and adjusts the patient's plan of care. The nurse knows this is applying which characteristic of the nursing process? a.Organization b.Dynamics c.Adaptability d.Collaboration
b.Dynamics Rationale: The nursing process is dynamic, reflecting changing conditions and needs of patients. Adjusting the plan of care after an outcome has been met is an example of this. Care plans should be organized. Care plans are adaptable, in that they are useful in multiple settings and with either individual or groups as the patient. Collaboration is a key component of meeting patient outcomes.
The nurse is admitting a patient experiencing chest discomfort and shortness of breath, who has a history of stroke. When the nurse documents the Nursing diagnosis "Risk for impaired mobility related to history of stroke," the nurse knows which condition to be the risk factor? a.Stroke b.History of stroke c.Chest discomfort d.Shortness of breath
b.History of stroke Rationale: A two-part risk, Nursing diagnostic statement contains only: (1) the patient's identified need or problem (i.e., NANDA-I Nursing diagnostic label) and (2) factors indicating vulnerability (i.e., risk factors). The risk factor is the history of stroke. The chest discomfort and shortness of breath are symptoms of the current problems and would not be documented as potential or "risk" issues. "Stroke" would be the identified potential problem.
In which step of the nursing process does the nurse prioritize the Nursing diagnoses and identify interventions to address the patient goals? a.Assessment b.Planning c.Implementation d.Evaluation
b.Planning Rationale: During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse writes a short-term goal for a patient scheduled for surgery in the morning and identifies which goal that contains all the necessary elements? a.The patient will walk to the bathroom within 48 hours after surgery. b.The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery. c.The patient will walk to the bathroom without experiencing shortness of breath. d.The patient will walk to the bathroom without experiencing shortness of breath after surgery.
b.The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery. Rationale: All short- and long-term goals must be: (1) patient focused, (2) realistic, and (3) measurable. For example, a patient-focused, realistic, and measurable short-term goal may be written for a patient with the Nursing diagnosis of Activity intolerance: The patient walks to the bathroom without experiencing shortness of breath within 48 hours after surgery.
The community health nurse is applying the nursing process to the care of patients with coronary artery disease. The nurse determines that most of the patients eat high-fat meals from local fast-food restaurants and plans a nutrition workshop. The nurse is applying which characteristic of the nursing process? a.Organization b.Dynamics c.Adaptability d.Collaboration
c.Adaptability Rationale: The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. The nurse has planned actions based on the needs of this specific population. Organization is another key concept, however; there is no information in the stem on organization. A care plan should be dynamic, changing over time to meet changing needs. The nurse may or may not have to collaborate with other providers in planning and conducting the seminar, but that is another characteristic of a good nursing care plan.
While the nurse is assisting with morning care, the patient has a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process? a.Assessment b.Planning c.Implementation d.Evaluation
c.Implementation Rationale: The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing? a.Assessment b.Diagnosis c.Implementation d.Evaluation
c.Implementation Rationale: The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The nurse knows which essential step was added in 1991? a.Assessment b.Diagnosis c.Outcome identification d.Evaluation
c.Outcome identification Rationale: The term nursing process was first used by Lydia Hall in 1955. In 1973, the American Nurses Association (ANA) identified five specific steps of the nursing process in its Standards of Clinical Practice (1991). These five steps—assessment, diagnosis, planning, implementation, and evaluation—define how professional nursing practice is conducted. Outcome identification was added as an essential aspect of the nursing process by the ANA in 1991. Most nursing professionals and educators recognize outcome identification as part of the planning step of the traditional five-step nursing process.
A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. When the nurse asks the manager if there is a document written by the physician for this type of reaction, the nurse is referring to which concept? a.Protocol b.Clinical pathway c.Standing order d.Care map
c.Standing order Rationale: Standing orders are written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when care is common to a certain type of situation, such as what to do if a patient experiences chest pain or what actions to take after a colonoscopy. Protocols are written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician's order. Health care agencies have established protocols outlining procedures for admitting patients or handling routine care situations. Clinical pathways, sometimes referred to as care pathways, care maps, or critical pathways, are multidisciplinary resources designed to guide patient care.
The nurse is assisting a patient to bed when the patient says, "My chest hurts and my left arm feels numb. What's wrong with me?" What is the type and source of data obtained from the patient's complaint? a.Objective data from a primary source b.Objective data from a secondary source c.Subjective data from a primary source d.Subjective data from a secondary source
c.Subjective data from a primary source Rationale: Objective data consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested. Subjective data are spoken. Primary data consist of information obtained directly from a patient. Secondary data are collected from family members, friends, other health care professionals, or written sources such as medical records and test results.
The nurse is caring for a patient who will be discharged home following surgical repair of a broken shoulder. The patient tells the nurse, "I don't have anyone at home who can help me cook my meals. Is there something you can do?" When demonstrating the adaptability of the nursing process, the nurse should carry out which task? a.Adjust the patient's care plan so that nursing goals can be met. b.Consult the care provider about extending the patient's hospitalization. c.Abandon the plan of care as not able to be done. d.Contact the social worker about community services.
d.Contact the social worker about community services. Rationale: The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. The nurse would adjust planning to contact the social worker for community resources so the patient can maintain as much independence as possible. The care plan focuses on the patient's goals. The provider may or may not be able to extend the hospital stay, but even if that were possible, the patient would not be able to stay until all function returned. The nurse does not simply abandon the care plan; the nurse looks for options and adaptations.
The nurse makes the following entry on the patient's care plan: "Goal not met. Patient refuses to walk and states, 'I'm afraid of falling.'" The nurse should complete which next action? a.Ignore the patient's concern in evaluating goal attainment. b.Document the patient's unwillingness to continue the plan of care. c.Continue the plan of care as originally agreed upon. d.Modify the care plan in response to the patient's condition and wishes.
d.Modify the care plan in response to the patient's condition and wishes. Rationale: Evaluation focuses on the patient and the patient's response to nursing interventions and goal or outcome attainment. If a goal was not met, the care plan needs to be modified to avoid simply repeating the same actions. Ignoring the patient is not a therapeutic response. The nurse should respect the patient's fear and assess further without simply documenting that the patient is unwilling.
The charge nurse is discussing a patient's care plan during a team meeting. The team determines that the patient has not met the goal of "ambulating to the nurse's station twice a day" and decides to revise the plan. The nurse recognizes which characteristic of the nursing process most represents this decision? a.Organization b.Dynamics c.Adaptability d.Outcome orientation
d.Outcome orientation Rationale: Patient care plans are developed to meet each patient's goals, not the goals of standardized patients or members of the health care team, including the nurse. Decisions regarding which nursing interventions and medical treatments to implement are made on the basis of safety and their effectiveness in meeting a patient's identified needs and desired outcomes. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any setting and at every level of care. The plan of care is individualized for the patient on the basis of assessment findings, changing needs, setting, and timing of interaction, not just outcomes. Following the steps of the nursing process ensures that patient care is well organized and thorough. The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. It is an equally useful method for addressing the needs of a specific population.