PrepU 16
b
The nurse recognizes that an example of a cognitive outcome is: a. The client demonstrates self-catheterization using clean technique by June 3. b. The client identifies three foods high in potassium by August 8. c. The client accurately measures the radial pulse for 1 minute by February 2. d. The client verbalizes increased confidence in testing glucose levels.
a
The nurse should derive the outcomes for a client's care plan from: a. the problem statement of the nursing diagnosis. b. the defining characteristics in the nursing diagnosis statement. c. assessment data gleaned from the physician's progress notes. d. assessment data provided by the multidisciplinary team.
a
Which statement correctly describes a nurse-initiated intervention? a. Nurse-initiated interventions are derived from the nursing diagnosis. b. Nurse-initiated interventions require a physician's order. c. Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. d. Nurse-initiated interventions are actions performed to diagnose a medical problem.
d
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
a
According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is: a. physiological. b. behavioral. c. safety. d. family.
a
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? a. Client will alternate rest periods with exercise throughout the day. b. Client will increase protein intake in small frequent meals. c. Client will use oxygen by nasal cannula when short of breath. d. Client will consistently perform pulmonary exercises.
c
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: a. diagnosis. b. evaluation. c. intervention. d. goal.
a
A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client? a. The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. b. The client will express an understanding of strategies for managing fatigue and shortness of breath. c. The client will ambulate 100 feet without supplementary oxygen or mobility aids. d. The client will demonstrate the correct use of a metered-dose inhaler.
a
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
The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually a. does not contain documented scientific rationales. b. does not contain abbreviated nursing diagnoses. c. separates goal statements from the plan of care. d. separates outcome criteria from the plan of care.
d
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? a. "I will take the medications until the inflammation goes away." b. "I will take my medications on an empty stomach for maximum effect." c. "I should increase water intake if I have dark bowel movements." d. "I should call my health care provider if I have a sore that won't heal."
b
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.
c
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? a. Maintenance b. Surveillance c. Psychomotor d. Psychosocial
b
Which guideline should the nurse follow when including interventions in a plan of care? a. Make sure the nursing interventions are unrelated to the original outcomes. b. Date the nursing interventions when written and when the plan of care is reviewed. c. Make sure the attending physician approves of and signs the nursing interventions. d. Make sure each nursing intervention does not describe the action the nurse should perform.
a
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: a. discharge planning. b. initial planning. c. ongoing planning. d. comprehensive planning.
a
Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs? a. Cutting up food and opening drink containers for the client b. Seeking input from the client regarding preferences for a snack c. Providing the mother the phone number for the Poison Control Center d. Assisting the client to validate feelings regarding treatment options
a
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? a. Narcotic analgesic to treat pain b. Septic workup due to blood pressure and heart rate elevation c. Isolation for suspected respiratory illness d. Acetaminophen to treat pain and fever
a
A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: a. a guideline. b. an algorithm. c. a critical pathway. d. an order set.
a
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
c
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? a. Process b. Structure c. Outcome d. Cost-effectiveness
a
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
A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? a. Individualize the plan to the client. b. Expect to modify the plan significantly. c. Identify the appropriate nursing diagnoses. d. Include the rationale for the interventions.
b
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? a. "You need to stop smoking for us to effectively combat this disease." b. "Please tell me your thoughts about treating this diagnosis." c. "Do you want to be discharged without treatment?" d. "What are your plans after discharge?"
c
Which outcome for a client with a new colostomy is written correctly? a. Explain to the client the proper care of the stoma by 3/29/20. b. The client will know how to care for the stoma by 3/29/20. c. The client will demonstrate proper care of the stoma by 3/29/20. d. The client will be able to care for stoma and cope with psychological loss by 3/29/20.
b
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? a. Posting the sign "NPO after midnight" over the bed b. Updating the diet orders in the client's plan of care c. Obtaining written consent for the diagnostic procedure d. Adding the diagnosis "Altered Nutrition, Less Than Required"
a
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? a. On the client's admission to the hospital b. Once the client has received a discharge order c. As soon as possible after the client's surgery d. Once the client is admitted to the nursing unit from postanesthetic recovery
a
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
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? a. Encourage hourly use of the incentive spirometer. b. Promote oral fluid intake between meals. c. Provide oral pain medication before ambulation. d. Reassess in 4 hours and document the findings.
b
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? a. Nursing diagnosis b. Outcome c. Intervention d. Evaluation
c
A nurse writes down the following outcome for a depressed client: "By 6/9/20, the client will state three positive benefits of receiving counseling." This is an example of which type of outcome? a. Psychomotor b. Cognitive c. Affective d. Realistic
a
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? a. Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. b. Assist the client to put on the clothing that goes over the operated leg. c. Tell the client's family to bring in clothes a size larger to make dressing easier. d. Arrange for the social worker to schedule home health care with discharge planning.
a
For which client would a standardized plan of care most likely be appropriate? a. A client who was admitted for shortness of breath and who has been diagnosed with pneumonia b. A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy c. A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem d. A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident
c
Which is an appropriate expected outcome for a client? a. By the next clinic visit, client will report taking antihypertensive medication. b. After attending sibling classes, client will be happy about a new baby and demonstrate feeding. c. Client will ambulate safely with walker in the room within 3 days of physical therapy. d. Client will perform complete ostomy care while bathing on the second postoperative day.
b
The nurse is developing goals for a newly admitted client with visual and auditory hallucinations. Which outcome is the priority for the client? a. Client will understand that the hallucinations aren't real in therapy sessions before discharge. b. Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior. c. Client will verbalize side effects of antipsychotic medications within 24 hours. d. Within 2 days, client will perform personal hygiene without reminders.
a
Which is an example of a psychomotor outcome? a. Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. b. Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. c. The client will verbalize understanding of the need to continue to take medications as prescribed. d. The client's skin will remain smooth, moist, and without breakdown or ulceration.
