Chapter 18: Planning Nursing Care Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

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 prioritizing her request?

1.

Low priority

2.

An unmet need

3.

Intermediate priority

4.

A safety and security need

ANS: 1

The clients request would be of low priority because it is not directly related to a specific illness or prognosis. An unmet need is not the most appropriate label for the clients request. The clients request is not an intermediate priority. An intermediate priority is one that involves the non-emergent, nonlife-threatening needs of the client. The clients request is not a safety and security need; the outcome does not threaten her well-being.

DIF: A REF: 262 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

2. Assuming that all of the following are realistic, a long-term goal for a client that is a tailor by trade and has been admitted for eye surgery should include:

1.

Returning to sewing

2.

Preventing ocular infection

3.

Administering eye drops on time in the hospital

4.

Performing independent hygienic care in the hospital

ANS: 1

Long-term goals focus on prevention, rehabilitation, discharge, and health education. An appropriate long-term goal for this client would be for rehabilitation and the clients return to occupation, in this case sewing. 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 1 week. In 1 weeks time, the clients risk for infection should be greatly reduced. Administering eye drops 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. 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.

DIF: A REF: 265 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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?

1.

Client will request pain medication as needed.

2.

Client will experience no headache or dizziness.

3.

Client will identify at least two things that cause stress.

4.

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

ANS: 4

Client will have a 7 AM blood pressure reading less than 140/90 would be the most appropriate outcome criterion. It is client-centered, singular, observable, measurable, time-limited, and realistic. Client will request pain medication as needed 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. Client will experience no headache or dizziness is not time-limited. Client will identify at least two things that cause stress is not time-limited or singular.

DIF: A REF: 266 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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

1.

Teaching a client to administer his or her insulin injection

2.

Assisting a new mother with learning the art of breast-feeding

3.

Notifying the nutritionist of a clients specific dietary preferences

4.

Administering a cleansing enema in preparation for radiological testing

ANS: 4

Preparing a client for a diagnostic test is an example of a physician-initiated intervention. Teaching a client to administer his or her insulin injection is an example of a nurse-initiated intervention. Assisting a new mother with breast-feeding is an example of a nurse-initiated intervention. Notifying a nutritionist of a clients dietary preferences is a collaborative intervention.

DIF: A REF: 268 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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

1.

Method

2.

Quantity

3.

Frequency

4.

Performing staff

ANS: 3

The intervention statement does not include how frequently the warm soaks should be applied. The method is applying warm, wet soaks to the patients leg while awake. The quantity is warm, wet soaks. The qualification of the person who will perform the action is the designation of the nurse.

DIF: A REF: 273 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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

1.

Client will describe activity restrictions.

2.

Client will verbalize understanding of treatments.

3.

Client will be ambulated in hallway 3 times each day.

4.

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

ANS: 4

Clients respiratory rate will remain within 20 to 24 breaths per minute by 9/24 is a correctly written outcome statement. It is client-centered, singular, observable, measurable, time-limited, and realistic. Client will describe activity restrictions is not time-limited. Client will verbalize understanding of treatments is not observable or time-limited. The client will state the purpose of the breathing treatments by 4/10 would be more appropriate. Client will be ambulated in hallway 3 times each day is not client-centered. A correct outcome statement would be Client will ambulate in the hall 3 times a day.

DIF: A REF: 267 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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?

1.

Nursing Kardex

2.

Computerized care plan

3.

Critical pathway

4.

Standardized care plan

ANS: 3

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

DIF: A REF: 274 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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?

1.

The problem area should be totally delegated to the consultant.

2.

Consultation is often used when the exact problem remains unclear.

3.

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

4.

Feelings about the problem should be described to the consultant by the nurse.

ANS: 2

Consultation is appropriate when the nurse has identified a problem that cannot be solved 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. 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. The person requesting the consult usually identifies the problem area. The nurse should not bias the consultant with subjective and emotional conclusions about the client and problem.

DIF: A REF: 276 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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?

1.

Difficulty breathing

2.

Financial problems

3.

A nutritional deficit

4.

An impending divorce

ANS: 1

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

DIF: C REF: 262 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

10. The nurse recognizes that client goals or outcomes should be documented according to specific criterion in order 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 the following:

1.

Vital signs will return to within normal levels for a middle aged adult.

2.

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

3.

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

4.

Output will be at least 100 mL/hour of clear yellow urine within 24 hours.

ANS: 4

Output will be at least 100 mL/hour of clear yellow urine within 24 hours. is client-centered, singular, observable, measurable, time-limited, and realistic. Vital signs will return to within normal levels for a middle aged adult. is not measurable (i.e., guidelines for normal are not stated), and it is not time-limited (e.g., by when?). Nursing assistant will ambulate the client in the hallway 3 times each day. is not client-centered. Lungs will be clear to auscultation and respiratory rate will be 20/minute. is not singular and it is not time-limited.

DIF: C REF: 267 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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

1.

Realistic

2.

Observable

3.

Measurable

4.

Client-centered

ANS: 1

The nurse sets realistic goals that can be achieved. This increases the clients motivation. The nurse also takes available resources into consideration in order to set realistic goals. Being observable means the nurse must be able to determine through observation if change has taken place. Being measurable means the goal is written so the nurse has a standard against which to measure the clients response to nursing care. Being client-centered means the goal should reflect the clients behavior and responses expected as a result of nursing interventions.

DIF: A REF: 267 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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

1.

Providing client teaching

2.

Administering medication

3.

Ordering a liver CAT scan

4.

Referring a client to physical therapy

ANS: 1

Health teaching is an example of a nurse-initiated intervention. Administering medication is a physician-initiated intervention. Ordering a CAT scan is a physician-initiated intervention. Referring a client to physical therapy is a collaborative intervention.

DIF: A REF: 267-268 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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

1.

Taking vital signs

2.

Providing support to a family

3.

Changing a dressing 2 times each day

4.

Measuring intake and output each shift

ANS: 3

Changing a dressing is a physician- or prescriber-initiated intervention. Taking vital signs is a nurse-initiated intervention. Providing support to a family is a nurse-initiated intervention. Measuring intake and output is a nurse-initiated intervention.

DIF: A REF: 268 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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

1.

Maintaining regular bowel elimination

2.

Promoting the health of the entire family

3.

Managing severely restricted body movement

4.

Restoring tissue integrity to areas damaged by friction

ANS: 4

Interventions to maintain or restore tissue integrity are classified as Level 2, Domain 2 (Physiological: Complex). Maintaining regular bowel elimination is classified as Level 2, Domain 1 (Physiological: Basic). Promoting the health of the family is classified as Level 2, Domain 5 (Family). Managing restricted body movement is classified as Level 2, Domain 1 (Physiological: Basic).

DIF: A REF: 270 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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

1.

Client outcomes

2.

Client assessment

3.

Nursing interventions

4.

Multidisciplinary approach

ANS: 4

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. Client outcomes are included in both critical pathways and traditional nursing care plans. Client assessment is necessary for developing and evaluating critical pathways and traditional nursing care plans. Nursing interventions are included in critical pathways and in the traditional nursing care plan.

DIF: A REF: 274 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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

1.

Offer fluids to the client q2h

2.

Observe the clients respirations

3.

Change the clients dressing daily

4.

Irrigate the nasogastric tube q2h with 30 ml normal saline

ANS: 4

Irrigate the nasogastric tube q2h with 30 ml normal saline is the most appropriate intervention statement. It includes the action, frequency, quantity, and method. Offer fluids to the client q2h lacks the component of quantity. Observe the clients respirations fails to indicate the frequency or method. Also, what is the reason for observation of the clients respirations? Change the clients dressing daily omits the method.

DIF: C REF: 267 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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

1.

Take vital signs.

2.

Refer client to a therapist.

3.

Turn client as needed while in bed.

4.

Apply two 4 4 dry gauze dressing pads tid.

ANS: 4

Apply two 4 4 dry gauze dressing pads tid. is the most appropriate. It identifies the action, frequency, quantity, and method. Take vital signs. fails to indicate the frequency and fails to completely indicate nursing actions (e.g., what parameters are used to notify the physician). Refer client to a therapist. fails to completely indicate nursing interventions (e.g., what type of therapist). Turn client as needed while in bed. fails to state an accurate frequency or precisely indicate the nursing actions.

DIF: A REF: 267 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

18. Care plans created by nursing 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:

1.

Client outcomes

2.

Nursing diagnoses

3.

Scientific rationales

4.

Nursing interventions

ANS: 3

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. Client outcomes are included in both student care plans and the clients record. Nursing diagnoses are included in both student care plans and the clients record. Nursing interventions are a component of both student care plans and a nursing care plan in the clients record.

DIF: A REF: 271 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

19. The purpose and distinction of a concept map, which a nurse may use when implementing a plan of care, are for:

1.

Multidisciplinary communication

2.

Quality assurance in the health care facility

3.

Provision of a standardized format for client problems

4.

Identification of the relationship of client problems and interventions

ANS: 4

A concept map is a diagram of client problems and interventions that shows their relationship to one another. Multidisciplinary communication is enhanced with the use of critical pathways, not concept maps. 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. Standardized or computerized care plans provide a standardized format for client problems, not the concept map. A concept map is highly individualized.

DIF: A REF: 274 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

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 upon the established criteria is the following:

1.

Client will perform glucose measurements often.

2.

Client will appear less anxious regarding diagnosis.

3.

Urinary output will reach normal young adult levels.

4.

Client will independently perform subcutaneous insulin injection by 8/31.

ANS: 4

Client will independently perform subcutaneous insulin injection by 8/31. 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. Client will perform glucose measurements often. does not specify a time frame. Client will appear less anxious regarding diagnosis. is not an appropriate outcome statement. There is no specific behavior observable for will appear. Urinary output will reach normal young adult levels. 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 is also not time-limited.

DIF: A REF: 267 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

21. Which of the following is the best example of an intermediate prioritized client need for a client diagnosed with risk of injury related to poor skin integrity?

1.

Applying adequate clothing to ensure the clients warmth

2.

Providing sufficient quantities of an aloe-based skin lotion

3.

Helping the client select her favorite foods from the menu form

4.

Dressing the clients feet in non-skid soled slippers when ambulating

ANS: 2

An intermediate priority is one that involves the non-emergent, nonlife-threatening needs of the client. Having sufficient aloe-based lotion is required for maintaining good skin integrity but is not required for meeting a life-threatening need. Although the other options are an intermediate need, they are not the best option because they are not directly related to the clients stated nursing diagnosis.

DIF: C REF: 262 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

22. Which of the following would be the best example of a short-term safety goal for a client who recently experienced abdominal surgery?

1.

The client will show no systemic or local signs of infection by time of discharge from hospital.

2.

The client will demonstrate an understanding of the proper use of patient-controlled analgesia (PCA).

3.

The client will demonstrate effective coughing and deep-breathing techniques within 2 hours of surgery.

4.

The client will consistently use the call bell to notify the staff of a need for assistance to the bathroom upon return to the nursing unit.

ANS: 4

Although all the options represent short-term goals, this option (consistently use the call bell to notify the staff) is directly related to client safety because it deals with fall prevention. Although this is short-term goal (by time of discharge), it is not as directly related to safety as some other options. Although this is short-term goal (time is inferred by nature of pain needs), it is not as directly related to safety as some other options. Although this is short-term goal (2 hours), it is not as directly related to safety as some other options.

DIF: C REF: 265 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

23. Which of the following would be the most appropriate outcome criterion for the goal, Clients pain will be managed to within an acceptable level within 30 minutes of receiving pain medication.

1.

Client will deny presence of any pain or discomfort.

2.

Client will rate pain at a level of 3 or less out of a possible 10.

3.

Client will demonstrate ability to request pain medication as needed.

4.

Client will identify two external factors that decrease presence of pain.

ANS: 2

Client will rate pain at a level of 3 or less out of a possible 10 would be the most appropriate outcome criterion because it is directly related to the management of pain levels as reflected by the pain scale. Client will deny presence of any pain or discomfort does not necessarily reflect a reasonable goal. Although client will demonstrate ability to request pain medication as needed is directed towards pain management, it does not have the primary focus that evaluating the pain management intervention has. Client will identify two external factors that decrease presence of pain is not the best option because it does not directly relate to pain management but the identification of contributing factors.

DIF: C REF: 266 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

24. The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in the morning. Which of the following client needs should take priority?

1.

Inventory of clothes and other personal belongings

2.

Orientation to the nursing unit and individual room

3.

Interview regarding medications currently being taken

4.

Assessment of body systems for presurgery checklist

ANS: 2

The clients admission has no acute physical needs and so the emotional need of familiarization with the environment has priority. Inventory of clothes and other personal belongings does not reflect a priority because it does not relate directly to a physical need, and there are other emotional needs of higher priority. Interview regarding medications currently being taken does not reflect a priority because it does not relate directly to a physical need, and there are emotional needs of higher priority. Although assessment of body systems for presurgery checklist reflects a needed nursing action, it is not a priority because it does not relate directly to physical need, and there are other emotional needs of higher priority.

DIF: C REF: 262 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

25. Which of the following outcomes, made by a nurse planning care for a client recently fitted with a hearing aid, best reflects an understanding of short-term client education goals?

1.

Client will properly clean the hearing aid ear piece daily with soap and water.

2.

Client will state 3 positive effects of wearing his hearing aid at follow-up appointment.

3.

Client will wear hearing aid while awake to help improve his ability to understand instructions.

4.

Client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today.

ANS: 4

Although all the options represent short-term goals, client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today is directly related to patient education because it relates to the proper care of the hearing aid. Client will properly clean the hearing aid ear piece daily with soap and water does not directly relate to client education but more to an expected client action. The goal does not include a time limit for compliance. Although client will state 3 positive effects of wearing his hearing aid at follow-up appointment may be a short-term goal (depends on time of next appointment), it is not as directly related to client education as it is compliance-oriented. Although client will wear hearing aid while awake to help improve his ability to understand instructions may be a short-term goal, although there is no time limit, it is not as related to client education as some other options.

DIF: C REF: 262-263 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

26. Which of the following statements made by a new nursing graduate best reflects an understanding of expected outcomes?

1.

It gives the client something positive to strive towards.

2.

They are statements of how the clients behavior should change.

3.

They are measurable criteria by which I can evaluation whether a goal has been achieved.

4.

They provide the client with suggestions on how to achieve their long and short term goals.

ANS: 3

They are measurable criteria by which I can evaluation whether a goal has been achieved. It is necessary to use expected outcomes or measurable criteria to evaluate goal achievement. Although outcomes are directed at times toward the alteration of client behavior, They are statements of how the clients behavior should change. is not the best option provided to reflect an understanding of the term. It gives the client something positive to strive towards and They provide the client with suggestions on how to achieve their long and short term goals are incorrect as outcomes are nursing-oriented, not client-oriented.

DIF: C REF: 266 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

27. A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the following statements best reflects an understanding of client-centered goals?

1.

The clients A1C levels will be 7 or below at the first testing date.

2.

The client will experience no blood sugar readings below 60 mg/dL before first follow up visit.

3.

The client will be visited weekly by home health nursing staff beginning 1 week after discharge.

4.

The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit.

ANS: 4

A client-centered goal is a specific and measurable behavior or response that reflects a clients highest possible level of wellness and independence in function, therefore The client will demonstrate the ability to appropriately measure blood sugar levels using a glucometer by discharge from nursing unit is correct. Although The clients A1C levels will be 7 or below at the first testing date and The client will experience no blood sugar readings below 60 mg/dL before first follow up visit are appropriate, they are not the best options because they do not reflect independence in function. The client will be visited weekly by home health nursing staff beginning 1 week after discharge is not client-centered because it does not reflect a clients highest possible level of wellness and independence in function.

DIF: C REF: 267 OBJ: Evaluation

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

28. The expected outcome that best evaluates the presurgical goal of, Client will understand purpose of coughing and deep breathing within 4 hours of returning to room is:

1.

Client will demonstrate proper technique for coughing and deep breathing

2.

Client will cough and deep breathe every 1 hour while awake without staff prompting

3.

Client is capable of restating the purpose of coughing and deep breathing in own words

4.

Clients lungs will be free of abnormal breath sounds within 1 hour of being returned to room

ANS: 2

An expected outcome is a criteria designed to evaluate the achievement of the stated goal. This option best represents evaluation of the clients understanding of the purpose of deep breathing and coughing because it shows appropriate compliance. Although demonstration evaluates the proper technique, it is not the best option to evaluate understanding of purpose. Although restatement evaluates understanding, it is not the best option to evaluate understanding of purpose because it does not include client compliance. The clients lungs being free of abnormal breath sounds within 1 hour is more reflective of a goal than of an expected outcome.

DIF: C REF: 266 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

29. Which of the following statements made by the nurse best reflects an understanding of the clients role in goal setting?

1.

He knows what he needs better than anyone else.

2.

When he sets the goals he is more likely to follow the plan.

3.

He identifies the goals and then together we create the plan of action.

4.

He is best suited to determine the level of effort he is capable of providing.

ANS: 4

Unless you set goals mutually and make a clear plan for action, clients will not follow the care plan. Clients alone are not always appropriately prepared to set and plan goals without professional help. Although the other answers may be true for many clients, it is not a guarantee that the client possesses all the skills and knowledge necessary to set and plan realistic goals.

DIF: C REF: 267 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

30. A nurse is caring for a client who experienced short-term memory loss as a result of a head injury. Which of the following statements made by the nurse regarding goal setting requires follow-up by the nurse manager?

1.

The client will certainly need frequent reorientation to the care plan goals.

2.

I will restate the goals Ive created for him regularly so as to win his compliance.

3.

Im not sure that his family will be able to support him with these goals but I will discuss it with them.

4.

He seems very willing to work towards achieving his goals but his condition will certainly create barriers.

ANS: 2

If a client or significant other is not able to participate in goal development, you assume responsibility until the client is able to participate. It is vital that to the degree that the client is capable, the client be included in the decision-making process. Frequent reorientation to the care plan goals may be true and so does not require follow-up. The nurse seems pessimistic about the familys ability to play a role in the clients care plan but declares that an attempt will be made to include them; so follow-up is not an immediate priority. The client seems very willing to work towards achieving his goals may be true and so does not require follow-up because there is no indication of the nurses intention to minimize his participation.

DIF: C REF: 265 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

31. Which of the following goals best shows that the nurse understands the concept of a client-centered goal?

1.

Client will consume at least 75% of each meal served.

2.

ADLs will be completed before breakfast is served.

3.

Pain will be managed so as to be rated at 3 or less out of 10.

4.

Client will be transported to physical therapy by 9 AM daily.

ANS: 1

Client will consume at least 75% of each meal served is correct. Outcomes and goals reflect the clients behavior and responses expected as a result of nursing interventions. Write a goal to reflect client behavior, not to reflect your goals or interventions. The other options are nursing-centered.

DIF: C REF: 267 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

32. Which of the following client-centered goals best rest reflects singular focus?

1.

Client will cough and deep breathe every hour while awake.

2.

Client will be free of shoulder and elbow pain by discharge.

3.

Client will adhere to a low-fat diet and lose 3 pounds in 30 days.

4.

Client will ambulate to the bathroom for the purpose of showering daily.

ANS: 4

Each goal and outcome addresses only one behavior or response. In this case the client will walk to the shower daily. Although coughing and deep breathing are usually done as a unit, they are really two separate actions. The client being free of shoulder and elbow pain by discharge relates to two different anatomical locations. Adhering to a diet and losing 3 pounds are two different actions.

DIF: C REF: 267 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

33. The nurse realizes that goals should be singular in focus primarily because:

1.

The nurse will find it difficult to modify the plan of care if the goals are not met.

2.

The client may not have the strength to accomplish multiply behavioral changes.

3.

The client may have difficulty focusing on more than one behavioral modification at a time.

4.

The nurse will find it difficult to identify appropriate interventions to address multiple behaviors.

ANS: 1

The nurse finding it difficult to modify the plan of care if the goals are not met is correct. Singularity allows you to decide if there is a need to modify the plan of care because only one response is considered. Although the other answers may be true, they are not the primary reason for having only one focus per goal.

DIF: C REF: 267 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

34. Which of the following goals concerning client anxiety is the best example of measurability?

1.

Client will be less anxious by discharge.

2.

Client will appear less anxious by discharge.

3.

Client will report anxiety at less than 3 out of 5 by discharge.

4.

Client pulse rate and blood pressure will be within normal limits by discharge.

ANS: 3

You need to be able to observe if change takes place in a clients status. Observable changes occur in physiological findings and the clients knowledge, perceptions, and behavior. You observe outcomes by directly asking clients about their condition or by using assessment skills. The client rating his anxiety is one method of observing improvement. The phrase will be less anxious is not observable. The phrase will appear less anxious is not observable. Although pulse rate and blood pressure may be affected by anxiety, there is no assurance that normal readings reflect an improvement.

DIF: C REF: 267 OBJ: Anxiety

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

35. Which of the following goals best reflects measurability?

1.

Clients emotional state will be stable by time of discharge.

2.

Client will experience normal sensations in feet by discharge.

3.

Client will report being free of shoulder pain by discharge.

4.

Client will have acceptable range of motion in elbow by discharge.

ANS: 3

Terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely. Pain free relates to quantity as well as quality. Do not use vague qualifiers such as normal, acceptable, or stable in an expected outcome statement. Vague terms result in guesswork in determining a clients response to care.

DIF: C REF: 267 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

36. When developing appropriate nurse-initiated interventions for a client admitted to an acute care facility for abdominal pain, the nurse must first consider:

1.

The institutions policies and procedures

2.

The states defined scope of nursing practice

3.

The clients physiological and psychological needs

4.

The scientific rationale for the proposed nursing action

ANS: 2

Each state within the United States has developed a Nurse Practice Act that defines the legal scope of nursing practice (see Chapter 22). According to the Nurse Practice Act in a majority of states, independent nursing interventions pertain to activities of daily living, health education and promotion, and counseling. Although the other answers must be considered, they are not the first consideration.

DIF: C REF: 268 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

37. The nurse realizes that the primary nursing responsibility regarding a physician-initiated intervention is to:

1.

Facilitate the intervention in a timely manner

2.

Evaluate the clients response to the intervention

3.

Possess the technical skills required to implement the intervention

4.

Provide client education regarding the implementation of the intervention

ANS: 3

Each physician-initiated intervention requires specific nursing responsibilities and technical nursing knowledge. Although the other options are expectations, they are not the primary consideration.

DIF: C REF: 268 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

38. The primary function of a care plan is to provide:

1.

The client with continuity of care

2.

The staff with written client-centered nursing interventions

3.

An established criteria for the evaluation of nursing outcomes

4.

An organized means of exchanging information between caregivers

ANS: 1

The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care. Although the rest are functions, they are not the primary function.

DIF: C REF: 269 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. Which of the following characteristics are considered guidelines for the writing of appropriate goals and outcomes? (Select all that apply.)

1.

Singular

2.

Realistic

3.

Practical

4.

Observable

5.

Measurable

6.

Meaningful

ANS: 1, 2, 4, 5

There are seven guidelines for writing goals and expected outcomes. The guidelines are client-centered, singular, observable, measurable, time-limited, mutual, and realistic. Practical and meaningful are not recognized characteristics

DIF: C REF: 269 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Health Promotion and Maintenance

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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