Chapter 17: Planning Nursing Care Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to assigning a priority for her request?

a.

Low priority

b.

An unmet need

c.

Intermediate priority

d.

A safety and security need

ANS: a

a. The clients request would be of low priority because it is not directly related to a specific illness or prognosis.

b. An unmet need is not the most appropriate label for the clients request.

c. The clients request is not an intermediate priority. An intermediate priority is one that involves the nonemergency, nonlife threatening needs of the client.

d. The clients request is not a safety and security need; the outcome does not threaten her well being.

REF: Text Reference: p. 319

2. The client is a tailor who was admitted for eye surgery. Assuming that all of the following are realistic, a long-term goal for this client should include:

a.

Returning to sewing

b.

Preventing ocular infection

c.

Performing independent hygienic care in hospital

d.

Administering eye drops on time in the hospital

ANS: a

a. Long-term goals focus on prevention, rehabilitation, discharge, and health education. An appropriate long-term goal for this client would be rehabilitation and the clients return to occupation.

b. Preventing ocular infection is a short-term goal. A short-term goal is expected to be achieved within a short time, usually in less than a week. In a weeks time, the clients risk for infection should be greatly reduced.

c. Performing independent hygienic care in the hospital is a short-term goal. Long-term goals are usually made for problem resolution after discharge; especially from an acute care setting.

d. Administering eyedrops on time in the hospital is a short-term goal. Long-term goals are usually designed for problem resolution after discharge, especially from an acute care setting.

REF: Text Reference: p. 322

3. The nurse writes the following goal for a client who is hypertensive: Client will maintain a blood pressure within acceptable limits. Which of the following would be the most appropriate outcome criterion?

a.

Client will request pain medication as needed.

b.

Client will identify at least two things that cause stress.

c.

Client will have a 7 AM blood pressure reading less than 140/90.

d.

Client will experience no headache or dizziness.

ANS: c

c. This option would be the most appropriate outcome criterion. It is client centered, singular, observable, measurable, time limited, and realistic.

a. This option does not allow the nurse to be able to determine if change has taken place. It would be more measurable to state the client will rate pain below 4 on a scale of 0- to 10 by 24 hours.

b. This option is not time limited.

d. This option is not time limited or singular.

REF: Text Reference: p. 323

4. Nursing interventions may be categorized based on the degree of nursing autonomy. Which of the following nursing interventions is considered as physician or prescriber initiated?

a.

Teaching a client to administer his or her insulin injection

b.

Assisting a new mother with breast-feeding

c.

Notifying the nutritionist of a clients dietary preferences

d.

Giving an enema in preparation for radiological testing

ANS: d

d. Preparing a client for a diagnostic test is an example of a physician-initiated intervention.

a. Teaching a client to administer his or her insulin injection is an example of a nurse-initiated intervention.

b. Assisting a new mother with breast-feeding is an example of a nurse-initiated intervention.

c. Notifying a nutritionist of a clients dietary preferences is a collaborative intervention.

REF: Text Reference: p. 324

5. Nursing interventions should be documented according to specific criteria so that they are clearly understood by other members of the nursing team. The intervention statement Nurse will apply warm, wet soaks to the patients leg while the patient is awake lacks which of the following components?

a.

Method

b.

Quantity

c.

Frequency

d.

Qualifications of the person who will perform the action

ANS: c

c. The intervention statement does not include how frequently the warm soaks should be applied.

a. The method is applying warm wet soaks to the patients leg while the patient is awake.

b. The quantity is warm wet soaks.

d. The qualification of the person who will perform the action is the designation of the nurse.

REF: Text Reference: p. 330

6. The nurse recognizes that client goals or outcomes should be documented according to specific criteria so that they are clear and easily understood by other members of the health care team. Of the following, the outcome statement that best meets the established criteria is:

a.

Client will describe activity restrictions

b.

Client will understand treatments

c.

Client will ambulate in hallway 3 times each day

d.

Clients respiratory rate will remain within 20- to 24/breaths per minute by 9/2d.

ANS: d

d. This is a correctly written outcome statement. It is client centered, singular, observable, measurable, time limited, and realistic.

a. This outcome statement is not time limited.

b. This outcome statement is not observable or time limited. The client will state the purpose of the breathing treatments by 4/10 would be more appropriate.

c. This outcome statement is not client centered. A correct outcome statement would be Client will ambulate in the hall 3 times a day.

REF: Text Reference: p. 323

7. The client is receiving postural drainage from physical therapy and intermittent breathing treatments from respiratory therapy. Which type of care plan would be the ideal method to document interventions for this client?

a.

Nursing Kardex

b.

Computerized care plan

c.

Critical pathway

d.

Standardized care plan

ANS: c

c. Critical pathways allow staff from all disciplines to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type.

a. The nursing Kardex is a card-filing system that allows quick reference to the particular needs of the client for certain aspects of nursing care.

b. A computerized care plan is a standardized care plan on the computer.

d. A standardized care plan is a prewritten plan created for a specific nursing diagnosis or clinical problem. The nurse individualizes the care plan for the clients needs.

REF: Text Reference: p. 330

8. The nurse is involved in requesting a management consultation for personnel-related issues. Which of the following is true regarding the consultation process in which the nurse is involved?

a.

The problem area is usually identified by another member of the health care team.

b.

Consultation is often used when the exact problem remains unclear.

c.

Detailed feelings about the problem should be described to the consultant by the nurse.

d.

The problem area should be totally delegated to the consultant.

ANS: b

b. Consultation is appropriate when the nurse has identified a problem that cannot be solved by using personal knowledge, skills, and resources, or when the exact problem remains unclear. A consultant objectively entering a situation can more clearly assess and identify the exact nature of the problem.

a. The person requesting the consult usually identifies the problem area.

c. The nurse should not bias the consultant with subjective and emotional conclusions about the client and problem.

d. The whole problem is not turned over to the consultant. The consultant is not there to take over the problem but is there to assist the nurse in resolving it.

REF: Text Reference: p. 335

9. In completing an assessment on an assigned client, the nurse obtains important information for planning nursing care. Which of the following client needs should take priority?

a.

An impending divorce

b.

A nutritional deficit

c.

Difficulty breathing

d.

Financial problems

ANS: c

c. Difficulty breathing would be the highest-priority client need. In general, priorities that protect clients basic needs of safety, adequate oxygenation, and comfort are considered high priority.

a. An impending divorce is a low-priority client need. It is a need that is not directly related to a specific illness or prognosis but may affect the clients future well being.

b. A nutritional deficit is an intermediate priority client need. It involves a nonlife threatening need of the client.

d. Financial problems are a low-priority client need. Financial problems are not directly related to a specific illness or prognosis but may affect the clients future well being.

REF: Text Reference: p. 319

10. The nurse recognizes that client goals or outcomes should be documented according to specific criteria so that they are clear and easily understood by other members of the health care team. Of the following, the outcome statement that best meets the established criteria is:

a.

Vital signs will return to normal

b.

Nursing assistant will ambulate the client in the hallway 3 times each day.

c.

Lungs will be clear to auscultation. and respiratory rate will be 20/breaths per minute

d.

Urinary output will be at least 100 ml per hour within 24 hours

ANS: d

d. This outcome statement is client centered, singular, observable, measurable, time limited, and realistic.

a. This outcome criterion is not measurable (i.e., guidelines for normal are not stated), and it is not time limited (i.e., by when?).

b. This outcome statement is not client centered.

c. This outcome statement is not singular and it is not time limited.

REF: Text Reference: p. 323

11. In goal setting, the nurse is aware that the factor that is associated with available client resources and motivation is:

a.

Client centered

b.

Observable

c.

Measurable

d.

Realistic

ANS: d

d. The nurse sets realistic goals that can be achieved. This increases the clients motivation. The nurse also takes available resources into consideration to set realistic goals.

a. Being client-centered means that the goal should reflect the client behavior and responses expected as a result of nursing interventions.

b. Being observable means the nurse must be able to determine through observation whether change has taken place.

c. Being measurable means the goal is written so the nurse has a standard against which to measure the clients response to nursing care.

REF: Text Reference: p. 324

12. Nursing interventions may be categorized based on the degree of nursing autonomy. An example of a nurse-initiated intervention is:

a.

Providing client teaching

b.

Administering medication

c.

Ordering a computed tomography (CAT) scan

d.

Referring a client to physical therapy

ANS: a

a. Health teaching is an example of a nurse-initiated intervention.

b. Administering medication is a physician-initiated intervention.

c. Ordering a computed tomography (CAT) scan is a physician-initiated intervention.

d. Referring a client to physical therapy is a collaborative intervention.

REF: Text Reference: p. 324

13. Nursing interventions may be categorized based on the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated?

a.

Taking vital signs

b.

Providing support to a family

c.

Changing a dressing 2 times each day

d.

Measuring intake and output each shift

ANS: c

c. Changing a dressing is a physician- or prescriber-initiated intervention.

a. Taking vital signs is a nurse-initiated intervention.

b. Providing support to a family is a nurse-initiated intervention.

d. Measuring intake and output is a nurse-initiated intervention.

REF: Text Reference: p. 324

14. Which one of the following interventions selected by the nurse is classified as Level 2, Domain 2 (Physiological: complex)?

a.

Maintaining regular bowel elimination

b.

Promoting the health of the family

c.

Managing restricted body movement

d.

Restoring tissue integrity

ANS: d

d. Interventions to maintain or restore tissue integrity are classified as Level 2, Domain 2 (Physiological: Complex).

a. Maintaining regular bowel elimination is classified as Level 2, Domain 1 (Physiological: Basic).

b. Promoting the health of the family is classified as Level 2, Domain 5 (Family).

c. Managing restricted body movement is classified as Level 2, Domain 1 (Physiological: Basic).

REF: Text Reference: p. 326

15. In documentation of nursing care plans, critical pathways differ from traditional nursing care plans in there:

a.

Multidisciplinary approach

b.

Nursing interventions

c.

Client outcomes

d.

Client assessment

ANS: a

a. Critical pathways are multidisciplinary. They allow staff from all disciplines, such as medicine, nursing, pharmacy, and social work, to develop integrated care plans for a projected length of stay or number of visits for clients with a specific case type.

b. Nursing interventions are included in critical pathways and in the traditional nursing care plan.

c. Client outcomes are included in both critical pathways and traditional nursing care plans.

d. Client assessment is necessary for developing and evaluating critical pathways and traditional nursing care plans.

REF: Text Reference: p. 330

16. Nursing interventions should be documented according to specific criteria so that they are clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is:

a.

Offer fluids to the client q2h

b.

Observe the clients respirations

c.

Change the clients dressing daily

d.

Irrigate the nasogastric tube q2h with 30 ml normal saline

ANS: d

d. This is the most appropriate intervention statement. It includes the action, frequency, quantity, and method.

a. This intervention statement lacks the component of quantity.

b. This intervention statement fails to indicate the frequency or method (i.e., what is the observer specifically looking for?).

c. This intervention statement omits the method.

REF: Text Reference: p. 329

17. Nursing interventions should be documented according to specific criteria so that they are clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is:

a.

Apply dry dressing with two 4 4 inch gauze pads tid

b.

Turn client in bed as needed

c.

Take vital signs

d.

Refer client to a therapist

ANS: a

a. This intervention statement is the most appropriate. It identifies the action, frequency, quantity, and method.

b. This intervention statement fails to state an accurate frequency or precisely to indicate the nursing actions.

c. This intervention statement fails to indicate the frequency and completely fails to indicate nursing actions (i.e., what are the parameters to notify the physician?).

d. This intervention statement fails to indicate completely the nursing interventions (i.e., what type of therapist?).

REF: Text Reference: p. 329

18. Care plans for students usually differ from those that are completed by nurses working on client units. An aspect of the plan that is usually included in the students care plan, but not in the clients record, is:

a.

Nursing diagnoses

b.

Client outcomes

c.

Nursing interventions

d.

Scientific rationales

ANS: d

d. An aspect of a nursing care plan that is usually included in the students care plan, but not in the clients record, is scientific rationales.

a. Nursing diagnoses are included in student care plans and the clients record.

b. Client outcomes are included in both student care plans and the clients record.

c. Nursing interventions are a component of both student care plans and a nursing care plan in the clients record.

REF: Text Reference: p. 329

19. A nurse may use a concept map when implementing a plan of care. The purpose and distinction of a concept map is for:

a.

Quality assurance in the health care facility

b.

Multidisciplinary communication

c.

Provision of a standardized format for client problems

d.

Identification of the relation of client problems and interventions

ANS: d

d. A concept map is a diagram of client problems and interventions that shows their relations to one another.

a. The use of a concept map promotes critical thinking and helps nurses to organize complex client data, process complex relationships, and achieve a holistic view of the clients situation. The purpose is not quality assurance in the health care facility.

b. Multidisciplinary communication is enhanced with the use of critical pathways, not concept maps.

c. Standardized or computerized care plans provide a standardized format for client problems, not the concept map. A concept map is highly individualized.

REF: Text Reference: p. 333

20. A client is newly diagnosed with diabetes mellitus. The nurse identifies a nursing diagnosis of: Knowledge deficient related to new diagnosis and treatment needs. The most appropriate outcome statement based on the established criteria is:

a.

Client will perform glucose measurements often

b.

Client will appear less anxious about diagnosis

c.

Urinary output will reach normal levels

d.

Client will independently perform subcutaneous insulin injection by 8/3a.

ANS: d

d. This option is the most appropriate outcome statement. It addresses the nursing diagnosis by identifying a singular outcome the client can realistically achieve, is observable, and provides a time frame.

a. This is not an appropriate outcome statement. It does not specify a time frame.

b. This is not an appropriate outcome statement. No specific behavior is observable for will appear.

c. This is not an appropriate outcome statement. It does not provide a standard against which to measure the clients response to nursing care, and therefore is not measurable. It also is not time limited.

REF: Text Reference: p. 322

Copyright 2005 by Mosby, Inc. All rights reserved.

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