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ANS: BIn the five-step nursing process, the nurse should establish mutual goals with the patient and prioritize care in the planning phase, which follows the diagnosis phase. The assessment phase of the nursing process involves gathering data. The implementation phase involves carrying out appropriate nursing interventions. During the evaluation phase, the nurse assesses the effectiveness of interventions.
2. A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first bya.Asking physical therapy to assist the patient because of the new injuries.b.Disregarding all previous diagnoses and establishing a new plan of care.c.Reassessing the patient.d.Setting new priorities for the patient.
ANS: CThe nurse needs to reassess the patient after any type of change in health status. The nursing process is dynamic and ongoing. Asking physical therapy to assist the patient is premature before reassessing the patient and awaiting physician orders. The nurse may not need to disregard all previous diagnoses. Some diagnoses may still apply, but the patient needs to be reassessed first. Setting new priorities is not recommended before assessment and establishing diagnoses.
3. When planning patient care, a goal can be described asa.A statement describing the patient’s accomplishments without a time restriction.b.A realistic statement predicting any negative responses to treatments.c.A broad statement describing a desired change in patient behavior.d.An identified long-term nursing diagnosis
ANS: CA goal is a broad statement that describes a desired change in a patient’s condition or behavior. A goal is mutually set with the patient and is time-limited, patient-centered, measurable, and realistic.
4. When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility bya.Ambulating in the hallway two times this shift.b.Turning side to back to side with assistance every 2 hours.c.Using the walker correctly to ambulate to the bathroom as needed.d.Using a sliding board correctly to transfer to the bedside commode as needed.
ANS: BThe patient is ordered to be on bed rest; therefore turning the patient in bed is the only option that is appropriate. When determining goals, the nurse needs to ensure that the goal is individualized and realistic for the patient.
5. The following statements are on a patient’s nursing care plan. Which of the following statements is written as an outcome?a.The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.b.The patient will demonstrate increased mobility in 2 days.c.The patient will demonstrate increased tolerance to activity over the next month.d.The patient will understand needed dietary changes by discharge.
ANS: AAn expected outcome is a specific and measurable change that is expected as a result of nursing care. The other three options in this question are goals. Demonstrating increased mobility in 2 days and understanding necessary dietary changes by discharge are short-term goals because they are expected to occur in less than a week. Demonstrating increased tolerance to activity over a month-long period is a long-term goal because it is expected to occur over a longer period of time.
6. Which patient outcome statement includes all seven guidelines for writing goal and outcome statements?a.The patient will ambulate in hallways.b.The nurse will administer pain medication every 4 hours to keep the patient free from discomfort.c.The nurse will monitor the patient’s heart rhythm continuously this shift.d.The patient will feed self at all mealtimes today without complaints of shortness of breath.
ANS: DA goal or outcome statement should be patient-centered; should address one patient response; should be observable, measurable, and time-limited; should be mutually set by nurse and patient; and should be realistic. The statement “The patient will feed self at all mealtimes today without complaints of shortness of breath” includes all seven criteria for goal writing. “The patient will ambulate in hallways” is missing a time limit. Administering pain medication and monitoring the patient’s heart rhythm are nursing interventions; they do not reflect patient behaviors or actions.
7. A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems that a nurse can treat. While developing the plan of care, which nursing diagnosis is the highest priority for this patient?a.Risk for impaired skin integrityb.Risk for infectionc.Spiritual distressd.Reflex urinary incontinence
ANS: DReflex urinary incontinence is highest priority. If a patient’s incontinence is not addressed, then the patient is at higher risk of impaired skin integrity and infection. Remember that the Risk for diagnoses are potential problems. They may be prioritized higher in some cases, but not in this situation. Spiritual distress is an actual diagnosis, but the adverse effects that could result from not assisting the patient with urinary elimination take priority in this case. Physiological problems do not always take priority, but the greatest harm could come to this patient if urinary incontinence is not prioritized
8. The nurse is caring for seven patients this shift. After completing their assessments, the nurse states that he doesn’t know where to begin in developing care plans for these patients. Which of the following is an appropriate suggestion by another nurse?a.“Choose all the interventions and perform them in order of time needed for each one.”b.“Make sure you identify the scientific rationale for each intervention first.”c.“Decide on goals and outcomes you have chosen for the patients.”d.“Begin with the highest priority diagnoses, then select appropriate interventions.”
ANS: DWhen developing a plan of care, the nurse needs to rank the nursing diagnoses in order of priority, then select appropriate interventions. Choosing all the interventions should take place after ranking of the diagnoses, and interventions should be prioritized by patient needs, not just by time. The chosen interventions should be evidence-based with scientific rationales, but the diagnoses need to be prioritized first to prioritize interventions. Goals for a patient should be mutually set, not just chosen by the nurse.
9. A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?a.Individualize the care plan only according to the patient’s needs.b.Request that the son leave at bedtime, so the patient can rest.c.Suggest that a female member of the family stay with the patient.d.Involve the son in the plan of care as much as possible.
ANS: DFamily should be included in the plan of care as much as possible. The family is a resource to help patients meet health care goals. Meeting some of the family’s need as well as the patient’s needs will possibly improve the patient’s level of wellness. The son should not be asked to leave if at all possible. In some situations, it may be best that family members not remain in the room, but no evidence in the question stem suggests that this is the case in this situation. Suggesting that a female member of the family stay is not justified without a legitimate reason. No reason is given in this question stem for such a suggestion.
10. Which of these outcomes would be most appropriate for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications?a.Patient will have one soft, formed bowel movement by end of shift.b.Patient will not take any pain medications this shift.c.Patient will walk unassisted to bathroom by the end of shift.d.Patient will not take laxatives or stool softeners this shift.
ANS: AThe identified problem, or nursing diagnosis, is Constipation. Therefore, the outcome should be that the constipation is relieved. To measure constipation relief, the nurse will be observing for the patient to have a bowel movement. Not taking pain medications may or may not relieve the constipation. Although not taking pain medicines might be an intervention, the nurse doesn’t want the patient to be in pain to relieve constipation. Other measures, such as administering laxatives or stool softeners, might be appropriate interventions. The patient walking unassisted to the bathroom addresses mobility, not constipation. The patient may need to walk to the bathroom to have a bowel movement, but the appropriate outcome for constipation is that the constipation is relieved as evidenced by a bowel movement—something that the nurse can observe.
11. The nurse recognizes that another term for a collaborative nursing intervention is _____ intervention.a.Dependent b.Independent c.Interdependent d.Physician-initiated
ANS: CA collaborative, or interdependent, intervention requires the combined knowledge, skill, and expertise of multiple health care professionals. A dependent intervention requires an order from a health care professional. An independent intervention is an action that the nurse initiates.
12. A registered nurse administers pain medication to a patient suffering from fractured ribs. What type of nursing intervention is this nurse implementing?a.Collaborativeb.Independentc.Interdependentd.Dependent
ANS: DThe nurse does not have prescriptive authority to order pain medications, unless the nurse is an advanced practice nurse. The intervention is therefore dependent. A collaborative, or interdependent, intervention involves therapies that require combined knowledge, skill, and expertise from multiple health care professionals. An independent intervention does not require an order or collaboration with other professionals.
13. The nurse describes evidence-based practice asa.Practice based on the evidence presented in court.b.Implementing interventions based on scientific rationale.c.Using standardized care plans.d.Planning care based on tradition.
ANS: BThe best answer is implementing interventions based on scientific rationale. Practice based on evidence presented in court is incorrect. Practice is based on current research. Using standardized care plans may be one example of evidence-based practice, but there are many others as well. The nurse must be careful in using standardized care plans to ensure that each patient’s plan of care is still individualized. Planning care based on tradition is incorrect because nursing care should be based on current research.
14. Which intervention is most appropriate for the nursing diagnostic statement, Impaired verbal communication related to loss of facial motor control and decreased sensation?a.Obtain an interpreter for the patient as soon as possible.b.Assist the patient in performing swallowing exercises each shift.c.Ask the family to provide a sitter to remain with the patient at all times.d.Provide the patient with a writing board each shift
ANS: DThe cause of the patient’s problem will help guide the nurse to the proper nursing intervention. If the patient has a problem with verbal communication, then the nurse should choose an intervention that will address the problem. Providing the patient with a writing board will allow the patient to communicate by writing because the patient is unable to communicate verbally at this time. Obtaining an interpreter might be an appropriate intervention if the patient spoke a foreign language. Assisting with swallowing exercises will help the patient with swallowing, which is a different nursing diagnosis from Impaired verbal communication. Asking the family to provide a sitter at all times is many times unrealistic and does not promote the patient’s independence, as does providing a writing board.
15. Which intervention is most appropriate for the nursing diagnostic statement, Impaired skin integrity related to shearing forces?a.Administer pain medication every 4 hours as needed.b.Perform the ordered dressing change twice daily.c.Do not document the wound appearance in the chart.d.Keep the bed side rails up at all times.
ANS: BThe most appropriate intervention for the diagnosis of Impaired skin integrity is to perform the ordered dressing change. The other options do not directly address the skin integrity. The patient may need pain medication before dressing changes, but Acute pain would be another nursing diagnosis. Documenting all objective findings is the nurse’s responsibility, even if a wound or infection is a health care–associated problem. Keeping the side rails up addresses safety, not skin integrity.
16. A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement, Risk for falls?a.Encourage patient to remain in bed most of the shift.b.Keep all side rails down at all times.c.Place patient in room away from the nurses’ station if possible.d.Assist patient into and out of bed every 6 hours or as tolerated.
ANS: DRisk for falls is a potential nursing diagnosis; therefore the nurse needs to implement actions that will prevent a fall. Assisting the patient into and out of bed is the most appropriate intervention to prevent the patient from falling. Encouraging activity builds muscle strength, and helping the patient with transfers ensures patient safety. Encouraging the patient to stay in bed will not promote muscle strength. Decreased muscle strength is the risk factor placing the patient in jeopardy of falling. The side rails should be up, not down, according to agency policy. This will remind the patent to ask for help to get up and will keep the patient from rolling out of bed. The patient should be placed near the nurses’ station, so a staff member can quickly get to the room and assist the patient if necessary.
17. Which of the following options correctly explains what the nurse should do with the plan of care for a patient after it is developed?a.Place the original copy in the chart, so it cannot be tampered with or revised.b.Communicate the plan of care to all health care professionals involved in the patient’s care.c.Send the plan of care to the administration office to be filed.d.Send the plan of care to quality assurance for review
ANS: BThe patient’s nursing plan of care is a dynamic piece of work that needs to be updated and revised as the patient’s condition changes. All health care professionals involved in the patient’s care need to be informed of the plan of care. The plan of care is not placed on the chart and not ever looked at again. The plan of care is not sent to the administrative office or quality assurance office.
18. What is the first step in making a consult?a.Avoid bias by not providing a lot of information based on opinion to the consultant.b.Identify the problem.c.Provide the consultant with relevant information about the problem.d.Ensure that the right professional, with the appropriate knowledge and expertise, is contacted.
ANS: BThe nurse needs to first identify the problem. Subsequent steps in order include obtaining direct consultation with the right professional, providing the consultant with relevant information, avoiding bias, and being available to discuss the consultant’s recommendations.
19. A hospital’s wound nurse consultant made a recommendation for nurses on the unit to continue the patient’s dressing changes as previously ordered. The nurses on the unit should incorporate this recommendation into the patient’s plan of care bya.Assuming that the wound nurse will perform all dressing changes.b.Requesting that the physician look at the wound herself.c.Including dressing change instructions and frequency in the plan of care.d.Encouraging the patient to perform the dressing changes
ANS: CThe wound nurse clearly recommends that nurses on the unit, not the patient, should continue dressing changes. The nurses should not make a wrong assumption that the wound nurse is doing all the dressing changes. The recommendation states for the nurses to do the dressing changes. If the nurses feel strongly about obtaining another opinion, then the physician should be contacted. No evidence in the question suggests that the patient needs a second opinion.
1. A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. What factors does the nurse consider when prioritizing interventions? (Select all that apply.)a.Put all the patients’ nursing diagnoses in order of priority.b.Consider time as an influencing factor.c.Set priorities based solely on physiological factors.d.Utilize critical thinking.e.Do not change priorities once they’ve been established.
ANS: A, B, DThe nurse avoids setting priorities based solely on physiological factors. Consider psychosocial factors as well. Prioritizing the problems, or nursing diagnoses, will help the nurse decide which problem to address first. Time is a factor to be included in planning before continuing on to the implementation phase. Nurses use critical thinking throughout the entire nursing process. Priorities can change based on patient needs and responses to treatments. |
Which factor would be considered when choosing a nursing intervention to address a patient problem
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