107 OBJ: 8.2 TOP: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 2.. 107 OBJ: 8.1 TOP: Planning MSC:
Trang 1Practice 1st Edition Test Bank – Yoost
Chapter 08: Planning MULTIPLE CHOICE
1 The nurse is caring for a patient who has undergone abdominal surgery The patient stated prior to surgery that “I don’t think I’ll be able to handle this if I get
a colostomy I wouldn’t know how to manage it.” There is no “next of kin” listed
in the patient’s record The patient is complaining of severe surgical pain The nurse is correct when addressing which nursing diagnosis first?
Trang 2must be met before higher needs, such as self-esteem The first level is “physiologic” and includes basic survival needs such as airway patency, breathing, circulation, oxygen level, nutrition, fluid intake, body temperature regulation, warmth, elimination, shelter, sexuality, infection, and pain level The next level is “safety and security” includes
physical safety (prevention of falls and drug side effects) and knowledge of routines and procedures The level of “love and belonging” involves the need for love and affection, including compassion from the care provider, information from family and significant others, and strength of a support system “Self-esteem” refers to the need to feel good about oneself and includes changes in body image (from injury, surgery, puberty) and changes in self-concept
DIF: Remembering REF: p 107 OBJ: 8.2
TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
2 Setting priorities among identified nursing diagnoses is the first step in
the planning process The nurse is responsible for:
a monitoring patient responses
b carrying out the physician’s plan of care
c providing all interventions
d preventing interference from other disciplines
Trang 3Setting priorities among identified nursing diagnoses is the first step in the planning process The nurse is responsible for monitoring patient responses, making decisions culminating in a plan of care, and implementing interventions, including interdisciplinary collaboration and referral, as needed The nurse is significantly accountable for
achieving the desired outcomes
DIF: Remembering REF: p 107 OBJ: 8.1
TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
3 Which assessment made by the nurse should be addressed first?
a Reddened area to coccyx
b Decreased urinary output
Trang 4circulation—are a valuable tool for directing the nurse’s thought process Depending
on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds For instance, if a patient is in respiratory arrest, the most critical goal is for the patient to begin breathing The reddened coccyx, decreased urinary output, and surgical incision drainage are not immediately life threatening
DIF: Understanding REF: p 107 OBJ: 8.2 TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
4 Which should the nurse address first?
Trang 5matter of seconds For instance, if a patient is in respiratory arrest, the most critical goal is for the patient to begin breathing Pain, hunger, and decreased self-esteem are not immediately life threatening The absence of pulse is
DIF: Understanding REF: p 107 OBJ: 8.2 TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
5 The nurse has a thorough understanding of the planning phase of the
nursing process when stating:
a “Patients should be included in the planning process.”
b “Patient families should not interfere in the
Trang 6Planning is the third step of the nursing process During the planning phase, the
professional nurse prioritizes the patient’s nursing diagnoses, determines short- and term goals, identifies outcome indicators, and lists nursing interventions for patient-centered care Patients should be included in the planning process Involving patients in planning their care helps them to (1) be aware of identified needs, (2) accept realistic and measurable goals, and (3) embrace interventions to best achieve the mutually agreed-on goals Inclusion of patients in the planning process tends to improve goal attainment and patient cooperation with interventions By accepting guidance and input from patients during the planning process, the nurse provides them with a greater sense of
long-empowerment and control Depending on the patient’s condition or circumstances, it may be advantageous to include members of the patient’s support system (i.e., family, friends, and caregivers) in the planning phase
DIF: Understanding REF: p 106 OBJ: 8.2
TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
6 Goals are broad statements of purpose that describe the aim of nursing care
Trang 7d can be vague to facilitate evaluation of achievement
ANS: C
Goals are broad statements of purpose that describe the aim of nursing care Goals
represent short- or long-term objectives that are determined during the planning step Some sources establish time parameters for short- and long-term goals, whereas others do not According to Carpenito-Moyet, goals that are achievable in less than a week are short-term goals, and goals that take weeks or months to achieve are long-term goals Useful and effective goals have certain characteristics They are mutually acceptable to the nurse, patient, and family They are appropriate in terms of nursing and medical diagnoses and therapy The goals are realistic in terms of the patient’s capabilities, time, energy, and resources, and they are specific enough to be understood clearly by the
patient and other nurses They can be measured to facilitate evaluation
DIF: Understanding REF: pp 108-109 OBJ: 8.3 TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
7 In developing the nursing care plan, the nurse creates goals:
a with the patient and possibly the family
b that the nurse wants the patient to achieve
Trang 8c and actions needed to accomplish the goal
d that are aggressive to ensure success
ANS: A
The nurse creates goals with the patient and possibly with the family by discussing the patient’s current condition, the condition to which the patient wants to progress, and the actions the patient and nurse undertake to accomplish the goal The nurse’s input into this process is critical to developing reasonable goals and interventions Without the nurse’s guidance during this step, the goals and interventions may be too weak to
promote the patient’s success or too aggressive for the patient to achieve The nurse works with the patient to develop a plan of care that is reasonable, is appropriately challenging, and promotes patient success for goal attainment
DIF: Applying REF: p 109 OBJ: 8.5 TOP: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
8 Which statement is correct regarding diversity considerations?
a The male gender may struggle less with health
care terminology
b High numbers of minority populations do not
understand health teachings
Trang 9c Older adults have an easier time understanding
health teachings because of life experience
d Disabilities have no impact on the development of patient
care goals
ANS: B
High numbers of minority populations (particularly African American and Hispanic) and immigrants are unable to understand health teaching Patients of both genders, including those who are well educated and highly literate but have limited health care experience, may struggle with the complexity of health care terminology and procedures Older adults have particular problems with medical issues when they must assimilate new information or make complex decisions about treatments Before implementing teaching strategies to support goal attainment, the nurse must explore a patient’s disabilities and the effects they may have on achieving specific goals Successful accommodation of a patient’s disabilities should yield attainable goals that lead to positive outcomes
DIF: Understanding REF: p 108 OBJ: 8.3
TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
9 Which of the following is a correctly written example of a short-term goal?
a By attending the gym, the patient will lose 50 lb in 1
year
Trang 10b In 6 months, patient will be able to ambulate 1
mile without shortness of breath
c Patient will be able to change his colostomy bag within 6
short-DIF: Analyzing REF: p 109 OBJ: 8.4 TOP: Evaluation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
10 Which goal is written correctly for the nursing diagnosis of activity
intolerance related to imbalance between oxygen supply and demand?
a Patient will walk 1 mile without shortness of breath
Trang 11b Patient will ambulate 100 feet with no shortness of
breath on third day after treatment
c Patient will climb stairs without shortness of breath by
day 2 of hospital stay
d Patient will tolerate activity
ANS: B
Useful and effective goals have certain characteristics They are appropriate in terms of nursing and medical diagnoses and therapy The goals are realistic in terms of the patient’s capabilities, time, energy, and resources, and they are specific enough to be understood clearly by the patient and other nurses They can be measured to facilitate evaluation In option A, there is no time frame to gauge expectations so the diagnosis
is not measurable In option C, the number of stairs is not specified and so is not
measurable In option D, the type of activity is not mentioned so it is not specific and there is no measurable criterion
DIF: Analyzing REF: p 109 OBJ: 8.4 TOP: Evaluation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
11 The nurse recognizes which of the following as a barrier to achieving goals?
a The effects of pain and/or clinical depression
Trang 12b Patient involvement in setting patient goals
c Family involvement in setting patient goals
d Realistic expectations of the patient’s capabilities
ANS: A
Useful and effective goals have certain characteristics They are mutually acceptable to the nurse, patient, and family They are appropriate in terms of nursing and medical diagnoses and therapy The goals are realistic in terms of the patient’s capabilities, time, energy, and resources, and they are specific enough to be understood clearly by the patient and other nurses They can be measured to facilitate evaluation The nurse creates goals with the patient and possibly with the family by discussing the patient’s current condition, the condition to which the patient wants to progress, and the actions the
patient and nurse undertake to accomplish the goal The nurse must consider the effects
of conditions, such as severe pain related to recent surgery or clinical depression or hopelessness, on the ability of the patient to reach goals in a timely manner Other
barriers to goal attainment may be related to economic issues or available resources
DIF: Understanding REF: p 109 OBJ: 8.4
TOP: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
12 The nurse is caring for a patient who has had abdominal surgery but has
developed a slight temperature A patient-centered goal would be:
Trang 13a the patient’s temperature will return to normal within
activities Instead of focusing on the patient, the incorrect answers focus on the patient’s temperature, the nurse medicating the patient, and the patient’s skin integrity Only option D focuses on the patient
DIF: Understanding REF: p 109 OBJ: 8.5
Trang 1413 An example of a measurable goal would be:
a “The patient will be able to lift 10 lb by the end of
d “The patient will be able to life an acceptable amount of
weight by week one.”
ANS: A
Measurable goals are specific, with numeric parameters or other concrete methods of judging whether the goal was met When writing a goal statement with a patient, the nurse needs to clearly identify how achievement of the goal will be evaluated When terms such
as acceptable or normal are used in a goal statement, goal attainment is difficult to judge
because they are not measurable terms, unless they refer to laboratory values or diagnostic test findings The amount of weight a patient will lift at the end of the week is not
specified “Normal” and “acceptable” weight have not been defined
DIF: Analyzing REF: p 109 OBJ: 8.3 TOP: Evaluation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination
Trang 15evaluate the patient’s progress, the nurse is aware that evaluations:
a must be done at the end of every shift
b should be done at least every 24 hours
c depend on intervention and patient condition
d are always done at time of discharge
ANS: C
In most cases, goal statements need to include a time for evaluation The time depends
on the intervention and the patient’s condition Some goals may need to be evaluated daily or weekly, and others may be evaluated monthly The health care setting affects the time of evaluation If the goal is set during hospitalization, the goal may need to be evaluated within days, whereas a goal set for home care may be evaluated weekly or monthly At the time of evaluation, the goal is assessed for goal attainment, and new goals are set or a new evaluation date for the same goal may be chosen if the goal is still applicable for the patient care plan
DIF: Remembering REF: p 109 OBJ: 8.4
Trang 1615 The nurse knows that standardized care plans may be available and:
a need to be individualized for each patient
b are implemented without adjustment
c remove the need for nurse involvement
d do not require the use of nursing diagnoses
evaluation of outcomes In many agencies and specialty units, standardized care plans that must be individualized for each patient are available to guide nurses in the planning process
DIF: Remembering REF: p 110 OBJ: 8.5
Trang 17provider orders are:
complications Ordering heel protectors for patients susceptible to skin breakdown and initiating preventive measures (e.g., activity regimens, consultations with social workers, preadmission teaching) are often independent, nurse-initiated interventions Collaborative interventions require cooperation among several health care professionals and unlicensed assistive personnel (UAP) Collaborative interventions include activities such as physical therapy, home health care, personal care, spiritual counseling, medication reconciliation, and palliative or hospice care One method of determining interventions to meet patient outcome goals is to use the Nursing Interventions Classification (NIC), a comprehensive, research-based, standardized collection of interventions and associated activities NIC provides nurses with multidisciplinary interventions linked to each NANDA-I nursing diagnosis and a corresponding NOC
DIF: Remembering REF: p 112 OBJ: 8.6