Test bank for fundamentals of nursing active learning for collaborative practice 1st edition by yoost

During the planning phase, the professional nurse prioritizes the patient’s nursing diagnoses, determines short- and term goals, identifies outcome indicators, and lists nursing interven

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Fundamentals of Nursing Active Learning for Collaborative Practice 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?

must 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

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

ANS: A

Setting 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

3 Which assessment made by the nurse should be addressed first?

circulation—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

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 Pain, hunger, and decreased self-esteem are not

immediately life threatening The absence of pulse is

a “Patients should be included in the planning process.”

b “Patient families should not interfere in the planning

Planning 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

d 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

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

c and actions needed to accomplish the goal

d that are aggressive to ensure success

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

c Older adults have an easier time understanding health

teachings because of life experience

d Disabilities have no impact on the development of patient

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

b 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

DIF: Analyzing REF: p 109 OBJ: 8.4 TOP: Evaluation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:

b 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

measurable In option D, the type of activity is not mentioned so it is not specific and there is no measurable criterion

11 The nurse recognizes which of the following as a barrier to achieving goals?

a The effects of pain and/or clinical depression

b Patient involvement in setting patient goals

c Family involvement in setting patient goals

d Realistic expectations of the patient’s capabilities

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

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:

a the patient’s temperature will return to normal within 24

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

13 An example of a measurable goal would be:

a “The patient will be able to lift 10 lb by the end of week

d “The patient will be able to life an acceptable amount of

weight by week one.”

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

14 The nurse is formulating the patient’s care plan In determining when to evaluate 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

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

15 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

16 Nursing interventions that originate from the physician or primary care provider 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

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

18 Dependent nursing interventions include:

a ordering heel protectors

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

b dependent nursing interventions

c independent nursing interventions

ANS: A

Some interventions originate from health care provider orders These are dependent nursing interventions The nurse incorporates these orders into the patient’s overall care plan by associating each with the appropriate nursing diagnosis The ability of nurses to enact independent interventions has expanded in recent years, allowing nurses to initiate care that they recognize as essential in meeting patient needs or preventing

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 Assessment data are not considered interventions

20 Discharge planning begins:

a the day before discharge

c prior to admission

ANS: B

Discharge planning plays an important role in the success of a patient’s transition to the home setting after hospitalization Because most patients are in the hospital for only a short time, nurses must begin discharge planning on admission and continue until a patient is dismissed

21 The nurse is accurate when stating that adequate discharge planning:

a “May decrease the incidence of patients required to return

ANS: A

Research shows that comprehensive discharge planning reduces complications and

readmissions Home care planning adapts to the situation as the patient’s condition

improves or deteriorates as a result of advancing disease Because most patients are in the hospital for only a short time, nurses must begin discharge planning on admission and continue until a patient is dismissed

responsibility of: (Select all that apply.)

a prioritizing patient needs

b developing mutually agreed-on goals

c determining outcome criteria

d identifying interventions

e implementation of the patient’s plan of care

2 The nurse is formulating a plan of care for a patient In this phase of the nursing

process, the nurse: (Select all that apply.)

a prioritizes nursing diagnoses

b determines short and long-term goals

c identifies outcome indicators