PREP U CHAPTER 8

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)A standardized care plan B)An order set C)Guidelines D)An algorithm

A)A standardized care plan

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? A)Add the nursing diagnosis: Risk for Self-Harm. B)Tell another nurse about this client statement. C)Encourage the client to join a therapy group. D)Document that the depression has resolved.

A)Add the nursing diagnosis: Risk for Self-Harm.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? A)Client will have formed stools within 24 hours. B)Client will eat small meals of bland foods for 3 days. C)Client will identify the food that caused the condition within 3 hours. D)Client will maintain adequate hydration within 2 days.

A)Client will have formed stools within 24 hours.

Which is a common error nurses make when writing client outcomes? A)Expressing the client outcome as a nursing intervention B)Making the outcome measurable and including actions that are observable C)Including a target time by which the client is expected to achieve the outcome D)Including a subject, verb, conditions, performance criteria, and target time

A)Expressing the client outcome as a nursing intervention

Which statement correctly describes a nurse-initiated intervention? A)Nurse-initiated interventions are derived from the nursing diagnosis. B)Nurse-initiated interventions require a health care provider's order. C)Nurse-initiated interventions are actions deemed to have a low risk of harm D)to the client. E)Nurse-initiated interventions are actions performed to diagnose a medical problem.

A)Nurse-initiated interventions are derived from the nursing diagnosis.

A nursing student is writing a care plan for an assigned client to be submitted to the instructor. Before submitting the care plan the student reviews it to ensure that all the necessary components have been addressed. Which component would the student look for? Select all that apply. A)Nursing diagnoses B)Client goals C)Outcome criteria D)Interventions with rationales E)Evaluation F)Nursing Outcomes Classification

A)Nursing diagnoses B)Client goals C)Outcome criteria D)Interventions with rationales E)Evaluation

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? A)Ongoing B)Initial C)Discharge D)Outcome

A)Ongoing

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

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

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? A)Verb (action) B)Subject C)Conditions D)Performance criteria

A)Verb (action)

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using: A)assessment skills. B)nursing books. C)client's records. D)supervisor's advice.

A)assessment skills.

The nurse recognizes that identifying outcomes/goals must include: A)involvement of the client and family. B)input from the health care provider. C)input from the multidisciplinary team. D)involvement of the nurse manager and other staff nurses.

A)involvement of the client and family.

Which is a physician-initiated intervention? A)Teach the client how to transfer from bed to chair and chair to bed. B)Administer oxygen at 4 L/min per nasal cannula. C)Assist the client with coughing and deep breathing every hour. D)Monitor intake and output every 2 hours.

B)Administer oxygen at 4 L/min per nasal cannula.

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? A)The nurse has not made any error in writing the outcome. B)The nurse has omitted the time frame. C)The nurse has omitted the defining characteristics. D)The outcome should indicate what the nurse will do.

B)The nurse has omitted the time frame.

A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered? A)Initial planning B)Comprehensive planning C)Ongoing planning D)Discharge planning

C)Ongoing planning

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met? A)"I will take insulin until my blood sugar levels are normal." B)"I will take my medications between meals for maximum effect." C)"I will mix insulin glargine with insulin lispro at bedtime." D)"I will test my glucose level before meals and use sliding scale insulin."

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

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? A)Choosing actions that do not solve the problem B)Failing to update the written plan of care C)Beginning the plan without family to help D)Developing the plan without client input

D)Developing the plan without client input

When applying the nursing process, the nurse formulates client outcomes. Which would be most important for the nurse to include when writing client outcomes? A)Subject B)Condition C)Baseline assessment findings D)Qualifier

D)Qualifier