Ch. 16 Establishing Priorities Flashcards
A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply.
A) The nurse formulates nursing diagnoses.
B) The nurse identifies expected patient outcomes.
C) The nurse selects evidence-based nursing interventions.
D) The nurse explains the nursing care plan to the patient.
E) The nurse assesses the patient’s mental status.
F) The nurse evaluates the patient’s outcome achievement.
b, c, d. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the nursing care plan. Although all these steps may overlap, formulating and validating nursing diagnoses occur most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.
A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply.
A) A nurse sits down with a patient and prioritizes existing diagnoses.
B) A nurse assesses a woman for postpartum depression during routine care.
C) A nurse plans interventions for a patient who is diagnosed with epilepsy.
D) A busy nurse takes time to speak to a patient who received bad news.
E) A nurse reassesses a patient whose PRN pain medication is not working.
F) A nurse coordinates the home care of a patient being discharged.
b, d, e. Informal planning is a link between identifying a patient’s strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.
The nurse is helping a patient turn in bed and notices the patient’s heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning?
A) Initial planning
B) Standardized planning
C) Ongoing planning
D) Discharge planning
c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.
A nurse is prioritizing the following patient diagnoses according to Maslow’s hierarchy of human needs:
(1) Disturbed Body Image
(2) Ineffective Airway Clearance
(3) Spiritual Distress
(4) Impaired Social Interaction
Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow’s model?
A) 2, 4, 1, 3
B) 3, 1, 4, 2
C) 2, 4, 3, 1
D) 3, 2, 4, 1
a. 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow’s hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.
A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply.
A) The nurse uses a minimal practice standard and is able to alter care to meet the patient’s individual needs.
B) The nurse uses a binary decision tree for stepwise assessment and intervention.
C) The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes.
D) The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice.
E) The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research.
F) The nurse uses a decision tree that provides intense specificity and no provider flexibility.
a, c. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.
A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient?
A) Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge.
B) By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer.
C) By 6/19/20, the patient’s ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in).
D) By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.
d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient’s achievement of new skills; and (c) is an outcome describing a physical change in the patient.
A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome?
A) After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body.
B) By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself.
C) Following physical therapy, patient will begin to gradually participate in walking/running events.
D) By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events.
a. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person’s ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone’s ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.
A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written?
A) Offer the patient 60-mL fluid every 2 hours while awake.
B) During the next 24-hour period, the patient’s fluid intake will total at least 2,000 mL.
C) Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20.
D) At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day.
b. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: “Offer the patient 60-mL fluid every 2 hours while awake.” Correct: “The patient will drink 60-mL fluid every 2 hours while awake, beginning 1/3/20.” The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include “know,” “understand,” “learn,” and “become aware.”
A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis?
A) Actual
B) Possible
C) Risk
D) Collaborative
b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.
A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the “concepts” that are being diagrammed in this plan?
A) Protocols for treating the patient problem
B) Standardized treatment guidelines
C) The nurse’s ideas about the patient problem and treatment
D) Clinical pathways for the treatment of sickle cell anemia
c. A concept map care plan is a diagram of patient problems and interventions. The nurse’s ideas about patient problems and treatments are the “concepts” that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient’s situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.
