Prep U Chapter 13
The expected outcome for a client with a new diagnosis of diabetes mellitus (DM) is: client will describe appropriate actions when implementing the prescribed medication routine. Which statement by the client indicates the outcome expectation has been met?
"I will test my glucose level before meals and use sliding scale insulin."
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 client was admitted two days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?
Ongoing planning
A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?
Seek research about the disorder.
Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?
Standardized
An older adult female client has been admitted to hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which of the following statements constitutes a long-term outcome?
The client will return home able to conduct her activities of daily living without experiencing shortness of breath.
The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) is: client will describe appropriate actions when implementing the prescribed medication routine. Which statement by the client indicates the outcome expectation has been met?
"I should call my healthcare provider if I have a sore that won't heal."
The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate?
"Nursing interventions are pretty much the same for clients that have the same medical diagnosis."
A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?
Client is normal tensive.
A client with food poisoning has the nursing diagnosis "diarrhoea." Which expected client outcome most directly demonstrates resolution of the problem?
Client will have formed stools within 24 hours.
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
A nurse is planning nursing interventions for patients on a busy hospital ward. Which guideline would the nurse follow when designing the plan of care?
Date the nursing interventions when written and when the plan of care is reviewed.
A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?
Developing the plan without client input
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
These nursing diagnoses appear on a client's care plan. In what order will the nurse prioritize them?
Impaired swallowing Fluid volume deficit Risk for impaired skin integrity Altered body image
The nurse recognizes that identifying outcomes/goals must include which of the following?
Involvement of the client and family
The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?
Mr. Conner will demonstrate proper care of stoma by 3/29/15.
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?
Nurses do carry out interventions in response to a physician's order.
A nurse is writing goals for a patient who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this patient?
Over the next 24-hour period, the patient will walk the length of the hallway assisted by the nurse
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
Psychomotor
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.
Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal?
Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.
The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention?
Teach client how to splint abdominal incision when coughing and deep breathing.
The nurse has identified the following outcome for the client: The client will have a soft formed stool. Which error has the nurse made in writing the outcome?
The nurse has omitted the time frame.
A 63-year-old client in the ICU with a nursing diagnosis of risk for impaired skin integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to her left side she notices that the client has a non-blanching reddened area over her right trochanter. What would be the most appropriate action for the nurse to take?
The nurse repositions the client to her left side and updates the plan of care to turn and reposition the client every hour.
A nurse is planning care for a patient who has just been diagnosed with type 2 diabetes. Which nursing action is performed during the planning step of the nursing process?
The nurse selects nursing measures, including patient teaching
A nurse is giving post-operative care to a client after knee arthroplasty. Which of the following is a possible short-term goal for this client?
To ambulate the client to a bedside chair
A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?
Upon her admission to the hospital
A preceptor reviews the client outcomes written by a new nurse. Which outcome is the highest priority for the client with paranoid delusions?
Within 3 days, client will mingle in the day room without violence.
Which of the following is categorized as a psychomotor outcome?
Within two days of education, the client's wife will demonstrate abdominal dressing change.
The nurse is developing outcomes for the care plan of a patient admitted with Parkinson's disease. The nurse will derive the outcomes for this patient's care plan from:
the problem statement of the nursing diagnosis.
A nurse assesses the vital signs of a patient who is one day postsurgery in which a colostomy was performed. The nurse then uses the data to update the patient plan of care. What are these actions considered?
ongoing planning
The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?
"Please tell me your thoughts about treating this diagnosis."
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
Discharge planning
A nurse is demonstrating foley catheter care to a client. Which type of nursing intervention does this best represent?
Educational
