Basic Nursing Thinking Doing And Caring 2nd Edition By Treas – Test Bank
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Chapter 5. Planning Outcomes
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. For which patient would it be most important to perform a comprehensive
discharge plan?
1)
A teen who is a first-time mother, single, and lives with her parents
2)
An older adult who has had a stroke affecting the left side of his body and lives alone
3)
A middle-aged man who has had outpatient surgery on his knee and requires crutches
4)
A young woman who was admitted to the hospital for observation following an accident
ANS: 2
A comprehensive discharge plan should be developed for older adults and anyone who
has complex needs, including self-care deficits. The other patients do not have the
complex needs of the older adult patient who has had a stroke that affects body function.
PTS:1DIF:ModerateREF:p. 83
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis
____ 2. The nurse is beginning discharge planning for an older adult with left-side
weakness. All of the following are important, but which action is most important in
ensuring that the discharge plan is successful?
1)
Start planning at admission.
2)
Involve the family members.
3)
Get patient input when making the plan.
4)
Involve the multidisciplinary team.
ANS: 3
The discharge plan may be developed in a timely manner and involve the family and a
multidisciplinary team, but if the patient does not agree with the plan, it will not be
successful.
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 3. What do initial, ongoing, and discharge planning have in common?
1)
They are based on assessment and diagnosis.
2)
They focus on the patients perception of his needs.
3)
They require input from a multidisciplinary team.
4)
They have specific timelines in which to be completed.
ANS: 1
All planning is based on nursing assessment data and identified nursing diagnoses. The
patient should have input, but the planning is based on the nursing assessment. The
different types of planning are intertwined and may or may not be done at distinct,
separate times. Discharge planning often requires a multidisciplinary team, but initial and
ongoing planning may not. Initial planning is usually begun after the first patient contact,
but there is no specified time for completion; ongoing planning is more or less continuous
and is done as the need arises; discharge planning must be done before discharge.
PTS:1DIF:ModerateREF: p. 81-82
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 4. Which client has the greatest need for comprehensive discharge planning?
1)
A woman who has just given birth to her second child and lives with her husband and 18-
month-old daughter
2)
A man who has been readmitted for exacerbation of his chronic obstructive pulmonary
disease
3)
A 12-year-old boy who had outpatient surgery on his knee and lives with his mother
4)
A woman who was just diagnosed with renal failure and has started peritoneal dialysis
ANS: 4
Comprehensive discharge planning should be done for patients who have a newly
diagnosed chronic disease or have complex needs. The other patients may require
discharge planning but not as comprehensive as someone with a new diagnosis with
complex treatment.
PTS:1DIFifficultREF: p. 83
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 5. Which of the following is a benefit of standardized care plans, as defined in your
text? Standardized care plans
1)
Apply to every patient on a particular unit
2)
Include both medical and nursing orders
3)
Specify patient outcomes for each day
4)
Help ensure that important interventions are not overlooked
ANS: 4
Standardized care plans help promote consistency of care and ensure that important
interventions are not forgotten. They are not likely to apply to every patient on a unit
because they are usually single-problem plans or are used with a particular medical
diagnosis. Unlike protocols, they do not include medical orders. Unlike critical pathways,
they do not specify predicted patient outcomes for each day.
PTS:1DIF:ModerateREF: p. 86
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Recall
____ 6. How are standardized (model) care plans similar to unit standards of care?
Standardized (model) care plans
1)
Describe the care needed by patients in defined situations
2)
Include specific goals and nursing orders
3)
Become a part of the patients comprehensive care plan
4)
Usually describe ideal nursing care
ANS: 1
All of the statements are true for standardized care plans, but only 1 is true
of both standardized care plans and unit standards of care. Both describe care needed by
patients in defined situations, although unit standards usually describe care for groups of
patients (e.g., all women admitted to a labor unit), and standardized care plans are often
organized around a particular or all nursing diagnoses commonly occurring with a
particular medical diagnosis. Unit standards are more general and do not have goals for
each patient. Unit standards are kept on file in a central place on the unit and do not
become a part of the care plan. Unit standards describe minimal, not ideal, care.
PTS: 1 DIF: Difficult REF: p. 87; requires analysis of text discussion.
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 7. The nurse is planning care for a patient. She is using a standardized care plan for
Impaired Walking related to left-side weakness. Which of the following activities will the
nurse perform when individualizing the plan for the patient?
1)
Validate conflicting data with the patient.
2)
Transcribe medical orders.
3)
State the frequency for ambulation.
4)
Perform a comprehensive assessment.
ANS: 3
Individualizing the care plan means identifying specific problems, outcomes, and
interventions and the frequency of those interventions to meet the patients needs.
Validating data ensures your assessment is accurate. Transcribing orders is a part of
developing and implementing the care plan but not of individualizing the plan.
Performing an assessment is the beginning step to developing a care plan. Assessment
helps you to know the ways in which a standardized plan needs to be individualized.
PTS:1DIF:ModerateREF: p. 90
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
____ 8. Which of the following is the best example of an outcome statement? The patient
will
1)
Use the incentive spirometer when awake
2)
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Walk two times during day and evening shifts
3)
Maintain oxygen saturation above 92% while performing ADLs each morning
4)
Tolerate 10 sets of range-of-motion exercises with physical therapy
ANS: 3
Outcome statements should have specific performance criteria and a target time; maintain
oxygen saturation is the only one that meets those criteria. The incentive spirometer goal
should say how many times the incentive spirometer should be used each hour as well as
the volume. The walking goal should state how far the patient should walk. In the range-
of-motion goal, tolerate is a vague word and is difficult to measure, and the outcome
needs to specify how often.
PTS:1DIF:ModerateREF: p. 91-92
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 9. How are critical pathways and standardized nursing care plans similar? Both
1)
Specify daily, or even hourly, outcomes and interventions
2)
Prescribe minimal care needed to meet recommended lengths of stay
3)
Describe care common to all patients with a certain condition or situation
4)
Emphasize medical problems and interventions
ANS: 3
Both critical pathways and standardized care plans are preplanned documents; they
describe care common to all patients who have a certain condition (e.g., all patients who
have a heart attack need some of the same interventions). The other statements are true of
critical pathways but not of standardized nursing care plans.
PTS:1DIFifficultREF: dm 8687; high-level question, answer not given verbatim
____ 10. How is NOC different from the Omaha System?
1)
NOC can be used to write health restoration outcomes.
2)
NOC can be used in all specialty and practice areas.
3)
NOC can be used for individuals, families, or groups.
4)
NOC formulates goals based on nursing diagnoses.
ANS: 2
NOC was developed for all specialty and practice areas. The Omaha System was
developed for community health nursing. Both address health restoration and can be used
for individuals, family, or groups (community). Both base goals on nursing diagnoses,
although Omaha does not use the NANDA-I taxonomy.
PTS:1DIF:ModerateREF: p. 95; answer based on analysis of text discussion | V1, p. 98;
answer based on analysis of text discussion
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KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 11. How are short-term goals different from long-term goals? Short-term goals
1)
Can be met within a few hours or a few days
2)
Are developed from the problem side of the nursing diagnosis
3)
Must have target times/dates
4)
Specify desired client responses to interventions
ANS: 1
Short-term goals may be accomplished in hours or days; long-term goals usually are
achieved over weeks, months, or even years. The other statements are true for both short-
term and long-term goals.
PTS:1DIF:ModerateREF: p. 91
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 12. What do standardized nursing care plans and individualized care plans have in
common? They both
1)
Reflect critical thinking for a specific patient
2)
Are preprinted to apply to needs common to a group of patients
3)
Address a patients individual needs
4)
Provide detailed nursing interventions
ANS: 4
They both provide detailed nursing interventions, although the individualized care plan is
more specific to the patients needs and reflects critical thinking, whereas standardized
plans do not. It is not true of individual nursing care plans that they are preprinted and
apply to a group.
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 13. The nurse is individualizing Mr. Wus plan of care by writing a plan for his
nursing diagnosis of Anxiety. Why does the nurse need to write goals/outcomes on the
plan of care? Because outcomes describe
1)
Desired changes in the patients health status
2)
Specific patient responses to medical interventions
3)
Specific nursing behaviors to improve a patients health
4)
Criteria to evaluate the appropriateness of a nursing diagnosis
ANS: 1
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Outcomes describe changes in the patients health status in response to nursing, rather
than medical, interventions. Outcomes relate to patient behavior, not nursing behaviors.
Outcomes are a measure of the effectiveness of nursing care for a specific nursing
diagnosis, not whether the nursing diagnosis is appropriate.
PTS:1DIF:ModerateREF: p. 91
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension
____ 14. Which of the following outcome statements contains the best example of
performance criteria? The patient will
1)
Turn herself in bed frequently while awake
2)
Understand how to use crutches by day 2
3)
State that pain is decreased after being medicated
4)
Eat 75% of each meal without complaint of nausea
ANS: 4
Performance criteria should be specific and measurable. 75% of each meal is specific and
measurable. Frequently is vague. You cannot observe whether someone understands.
Decreased is vague; a numerical pain rating would be better.
PTS:1DIF:ModerateREF: p. 92
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application
____ 15. Which of the following is true for goals/outcomes for collaborative problems?
1)
They are monitored only by other disciplines.
2)
They are usually sensitive to nursing interventions.
3)
They state that a complication will not occur.
4)
They state only broad performance criteria.
ANS: 3
The goal for a collaborative problem is always that the complication will not occur. Other
disciplines may be involved in helping to prevent the problem, but nurses still monitor for
the complication. The outcomes to collaborative problems are not affected by nursing
interventions alone. Goals for collaborative problems are specific to the medical
condition/treatment.
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 16. How are NANDA-I problem labels and NOC outcome labels alike? Both
describe
1)
Health status in terms of human responses
2)
Patient response before interventions are done
3)
|
Patient response in positive terms
4)
A pattern of related cues
ANS: 1
Both NANDA-I and NOC labels are stated as human responses. A NOC label can be
used to describe patient responses both before and after interventionNANDA-I
before. NOC statements are neutral to allow for positive, negative, or no change in health
status; NANDA-I diagnoses describe both problem responses and positive responses
(wellness labels). NANDA-I labels are based on patterns of related cues; NOC labels are
based on (linked to) NANDA-I labels.
PTS: 1 DIF: Difficult REF: dm 94; also information about NANDA-I diagnoses from
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
____ 17. The nursing diagnosis is Impaired Memory related to fluid and electrolyte
imbalances A.M.B. inability to recall recent events. Which of the following
goals/outcomes must be included on the care plan?
1)
Checks current medications for mind-altering side effects
2)
Demonstrates use of techniques to help with memory loss
3)
Drinks at least 1500 cc of fluid per day
4)
Takes electrolyte supplements with meals
ANS: 2
The essential goal/outcome is aimed at the problem response Impaired Memory. The
other goals in this question address the etiology.
PTS:1DIF:ModerateREF: p. 93-94
KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application
____ 18. A client arrives in the emergency department, pale and breathing rapidly. He
immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses
the patient and decides the first series of actions that are needed. This scenario
demonstrates
1)
Formal planning
2)
Informal planning
3)
Ongoing planning
4)
Initial planning
ANS: 2
Informal planning is performed while doing other nursing process steps and is not
written; this nurse is forming a plan in her mind. The end product of formal planning is a
holistic plan of care that addresses the patients unique problems and strengths; this nurse
has no time to create a holistic plan of care. Ongoing planning refers to changes made in
the plan as you evaluate the patients responses to care; no care has been given at this
point. Initial planning does indeed begin with the first patient contact. However, it refers
to the development of the initial comprehensive plan or care; this nurse does not have
enough data for a comprehensive plan, nor does she have time to make such a plan at the
moment.
PTS:1DIF:EasyREF:p. 81
KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 1. A nurse is caring for an 80-year-old patient of Chinese heritage. When planning
outcomes for this patient, which actions by the nurse would meet the American Nurses
Association standards for outcomes identification? Choose all that apply.
1)
Developing culturally appropriate outcomes
2)
Using the outcomes preprinted on the clinical pathway
3)
Choosing the best outcome for the patient, regardless of the costs involved in bringing it
about
4)
Involving the patient and family in formulating the outcomes
ANS: 1, 4
ANA standard 3 includes derives culturally appropriate expected outcomes from the
diagnosis and involves the patient, family . . . in formulating expected outcomes. . . . It is
acceptable for the nurse to use outcomes on a clinical pathway, but these are not
individualized; ANA standard 3 says that the nurse identifies . . . outcomes for a plan
individualized to the patient. . . . The standard also says that the nurse should consider
associated risks, benefits, and costs. . . .
Chapter 6. Planning Interventions
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. Which of the following nursing interventions is an indirect-care intervention?
1)
Emotional support
2)
Teaching
3)
Consulting
4)
Physical care
ANS: 3
An indirect-care intervention is an activity performed away from the client on behalf of
the client. Indirect-care interventions include consulting with other healthcare team
members, making referrals, advocacy, and managing the environment. Direct-care
interventions include emotional support, patient teaching, and physical care.
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KEY: Nursing process: Implementation | Client need: SASE | Cognitive level: Recall
____ 2. Which nursing intervention is considered an independent intervention?
1)
Administering 1 L of dextrose 5% in normal saline solution at 100 mL/hour
2)
Encouraging the postoperative client to perform coughing and deep breathing exercises
3)
Explaining his diet to the client; then communicating the teaching with the dietitian
4)
Administering morphine sulfate 2 mg IV to the client with postoperative pain
ANS: 2
Encouraging the postoperative client to perform coughing and deep breathing exercises is
an independent nursing intervention. An independent intervention is one that nurses are
licensed to prescribe, perform, or delegate based on their skills and knowledge.
Administering IV fluid or morphine sulfate are dependent interventions; they require an
order from a physician or advanced practice nurse but are carried out by the nurse.
Explaining to the client how sodium intake affects his heart failure and then
communicating the teaching with the dietitian is an interdependent intervention, one that
is carried out in collaboration with other healthcare team members.
PTS:1DIF:ModerateREF: p. 103
KEY: Nursing process: Interventions | Client need: SASE | Cognitive level: Application
____ 3. A nurse makes a nursing diagnosis of Acute Pain related to the postoperative
abdominal incision. She writes a nursing order to reposition the client in a comfortable
position using pillows to splint or support the painful areas. What type of nursing
intervention did the nurse write?
1)
Collaborative
2)
Interdependent
3)
Dependent
4)
Independent
ANS: 4
Writing an order to reposition the client in a comfortable position is an example of an
independent nursing intervention, one that does not require a physicians order. The nurse
is licensed to prescribe, perform, or delegate the intervention based on her knowledge and
skills. A collaborative or interdependent intervention is one that is carried out in
collaboration with other health team members, such as providing the client with a
sodium-restricted diet. A dependent intervention is prescribed by a physician or advanced
practice nurse; for example, administer oxygen at 2 L/min via nasal cannula.
PTS:1DIF:ModerateREF: p. 103
KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive
level: Application
____ 4. The nurse is performing preoperative teaching for a client who is scheduled for
surgery in the morning. The client does not currently have any respiratory problems. The
nurses teaching plan includes coughing and deep breathing exercises. Which type of
nursing intervention is the nurse performing?
1)
Health promotion
2)
Treatment
3)
Prevention
4)
Assessment
ANS: 3
The nurse is teaching the client coughing and deep breathing exercises, which help
prevent postoperative pneumonia. Therefore, the nurse is utilizing a prevention
intervention. Prevention interventions are used to help prevent complications, such as
postoperative pneumonia. Health-promotion interventions promote a clients efforts to
achieve a higher level of wellness. Treatment interventions treat disorders, relieve
symptoms, and carry out medical orders. Assessment interventions detect changes in the
clients condition and detect potential problems.
PTS:1DIF:ModerateREF: p. 106
KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive
level: Application
____ 5. Which standardized intervention vocabulary was designed specifically for
community health nurses?
1)
Omaha System
2)
Clinical Care Classification
3)
Nursing Interventions Classification
4)
International Classification for Nursing Practice
ANS: 1
The Omaha System was designed specifically for community health nurses to use in
caring for individuals, families, community groups, or entire communities. The Clinical
Care Classification was developed for home healthcare. The Nursing Interventions
Classification system is applicable in all settings, including home health and community
nursing. The International Classification for Nursing Practice system was designed to
describe nursing practice of individuals, families, and communities worldwide.
PTS:1DIF:EasyREF: p. 110
KEY: Nursing process: Planning | Client need: SASE | Cognitive level: Recall
____ 6. A 55-year-old patient returned to the medical-surgical unit after undergoing a
right hemicolectomy (abdominal surgery) for colon cancer. Which of the following is an
appropriate, correctly written nursing order for this patient?
1)
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7/12/13 Encourage use of the incentive spirometer every hour while the client is awakeD.
Goodman, RN
2)
By 7/12/13, uses incentive spirometer 10 times every hour while awake to 1000 mL
3)
Incentive spirometer hourly while awake
4)
Offer incentive spirometer to the clientJ. Smith, RN
ANS: 1
The option beginning with a date and ending with the RNs signature contains necessary
information. It contains the date the order was written along with specific instruction for
the nurse that is written in terms of nursing behavior. Uses incentive spirometer 10 times
. . . is an example of an expected outcome. Incentive spirometer hourly . . . is an example
of a medical order. Plus, the date and nurses signature are missing. Offer incentive
spirometer . . . does not provide the nurse with enough detailed instruction. Therefore, it
is a poorly written nursing order.
KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitive level:
Application
____ 7. A client newly diagnosed with diabetes is admitted to the hospital because her
diabetes is out of control. Which of the following is an appropriate direct-
care intervention for this client during her stay?
1)
Consulting the diabetic nurse educator for help with a teaching plan
2)
Making arrangements for the client to join a diabetic support group
3)
Demonstrating blood glucose monitoring and insulin administration to the client
4)
Consulting with the dietician about the clients dietary concerns
ANS: 3
Demonstrating blood glucose monitoring and insulin administration is an appropriate
direct-care intervention for this client. Direct-care interventions are performed through
intervention with the client and include interventions such as physical care, emotional
support, and client teaching. Indirect-care activities include consulting the diabetic nurse
educator, making arrangements for the client to join a diabetic support group, and
consulting with the dietitian about the clients dietary concerns. Indirect-care activities are
performed away from but on behalf of the client.
PTS:1DIF:ModerateREF:p. 103
KEY: Nursing process: Interventions | Client need: Physiological integrity | Cognitive
level: Application
____ 8. Which definition best describes a critical pathway?
1)
Standardized plan of care for frequently occurring conditions
2)
Systematically developed statement to assist practitioners and patients in making
decisions
3)
Systematic review of clinical evidence for an intervention
4)
Set of interrelated concepts that describes or explains something
ANS: 1
Critical pathways are standardized plans of care for commonly occurring health
conditions (e.g., myocardial infarction) for which similar outcomes and interventions are
appropriate for the majority of patients with the condition. Clinical practice guidelines are
systematically developed statements to assist practitioners and patients in making
decisions about appropriate healthcare for a particular disease or procedure. Evidence
reports are systematic reviews on clinical topics for the purpose of providing evidence for
guidelines, quality improvement, quality measures, and insurance coverage decisions. A
theory is a set of interrelated concepts that describe or explain something.
PTS:1DIF:EasyREF: p. 104
KEY:Nursing process: N/A | Client need: SECE | Cognitive level: Recall
____ 9. A client is admitted to the hospital with an acute respiratory problem resulting
from lung disease. The nurse makes a diagnosis of Ineffective Breathing Pattern related
to inability to maintain adequate rate and depth of respirations. Which nursing
intervention should be listed first on the care plan?
1)
Determine airway adequacy hourly and as needed.
2)
Administer oxygen as needed.
3)
Monitor arterial blood gas values.
4)
Place the client in a high Fowlers position.
ANS: 1
For any acute respiratory problem, prior to implementing interventions, the nurse would
assess breathing status of the patient by checking the respiratory rate and depth. When
devising a plan of care for the client, nursing interventions should be listed according to
priority. Airway always takes precedence, as ventilation, oxygenation, and positioning
will be ineffective without a patent airway.
PTS: 1 DIF: Difficult REF: p. 107
KEY: Nursing process: Planning | Client need: Physiological integrity | Cognitive level:
Analysis
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