Ch. 8

Question 1

Which action would the nurse undertake first when beginning to formulate a patient’s plan of care?

Answer 1

Rank patient concerns from assessment data

Question 2

Which resource is most helpful when prioritizing identified nursing diagnoses?

Answer 2

Maslow’s hierarchy of needs

Question 3

If a patient is exhibiting signs and symptoms of each of the following nursing diagnoses, which should the nurse address first when planning care?

Answer 3

Acute pain

Question 4

Which statement illustrates a characteristic of goals within the care planning process?

Answer 4

Long-term goals are helpful in judging a patient’s progress

Question 5

Which nursing goal is written correctly for a patient with the nursing diagnosis of risk for infection after abdominal surgery?

Answer 5

Patients white blood count will remain within normal range throughout hospitalization.

Question 6

If the nurse chooses the NOC appetite (1014) for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment?

Answer 6

Expressed desire to eat.
Report that food smells good.
Preparation of home cooked meals for self and family.

Question 7

Which action by the nurse would be most important in developing a patient centered plan of care for an alert, oriented adult?

Answer 7

Listening to the patients concerns and beliefs about proposed treatment.

Question 8

Which interventions can the nurse initiate independently while providing patient care?

Answer 8

Auscultation lung sounds.
Monitoring skin integrity.
Applying heel protectors.

Question 9

The nurse notices that a patient is becoming short of breath and anxious. Which of the following interventions is a dependent nursing action, requiring the order of a primary care provider?

Answer 9

Administering oxygen by nasal cannula

Question 10

Which situation indicates the greatest need for collaborative interventions provided by several health care team members?

Answer 10

Hospice referral

Question 11

Articulate nursing actions that take place during the planning process

Answer 11

Professional nurse prioritizes the patients nursing diagnoses, determines short and long term goals, identifies outcome indicators and lists nursing interventions for patient centered care

Question 12

Describe various measures used in prioritizing patient care

Answer 12

Maslows hierarchy of needs and the ABCs of life support n the health care setting are helpful resources in prioritizing care. Collaboration with patients while developing goals can decrease the incidence of conflicting priorities.

Question 13

Illustrate an understanding of goal development

Answer 13

Goals need to be patient centered, realistic and measurable. Using measurable verbs and time limits when writing goals assists the nurse in evaluation of patient goal attainment.

Question 14

Describe the relationship between outcome identification and goal attainment.

Answer 14

Outcome identification involves listing observable behaviors or items that indicate attainment of a goal

Question 15

Identify formats in which patient centered plans of care can be developed.

Answer 15

Standardized care plans: individualized for each patient.
Conceptual care map: nursing students use for care plans - helps collect, analyze and synthesize patient data to identify appropriate diagnoses, goals and interventions.

Question 16

Distinguish among the types of interventions

Answer 16

Independent: nurse initiated and deemed essential
Dependent: require an order from primary physician
Collaborative: cooperation among health care team

Question 17

Discuss the importance of planning throughout patient care

Answer 17

Care planning begins when a patient and nurse first interact and continues until the patient no longer requires care.

Question 18

Five key elements for interventions

Answer 18

• patient assessment findings indicating signs and symptoms
• the underlying etiology
• realistic patient outcomes
• evidence based interventions
• expertise of the nurses and other health care pros and agencies

Question 19

Outcome indicators

Answer 19

Goal attainment is observed or measured

Question 20

Goals

Answer 20

Statements designed in collaboration with patients to provide guidance and ultimately a measure of progress when addressing nursing diagnoses

Question 21

Realistic goals

Answer 21

Consider patient’s physical, mental and spiritual condition in relation to the ability to attain goals.
Nurse must consider the effects of conditions (severe pain, clinical depression or hopelessness)
Other barriers to goal attainment may be related to economic issues or available resources.

Question 22

Patient centered goals

Answer 22

Written specifically for the patient.
Goal should specify the activity the patient is to exhibit or demonstrate to indicate goal attainment.
(Ambulating, eating, turning, coughing and deep breathing)

Question 23

Measurable goals

Answer 23

Specific, with numeric parameters or concrete methods of judging whether the goal was met.
Nurse needs to clearly identify how achievement of the goal will be evaluated

Question 24

Time limited goals

Answer 24

Depends on the intervention and the patients condition

Question 25

Conflicting priorities

Answer 25

When the nurse and patient have different beliefs and values regarding health practices

Question 26

ABCs of life

Answer 26

Airway
Breathing
Circulation

Question 27

Setting priorities

Answer 27

First step in the planning process.
Responsible for monitoring patient responses, making decisions culminating in a plan of care, and implementing interventions including interdisciplinary collaboration and referral.

Question 28

To begin planning

Answer 28

The nurse prioritizes each nursing diagnosis that is identified and establishes goals in collaboration with the patient.
Nurse identifies most urgent goals to be addressed, considers patients capabilities and then selects interventions to include in the patients individualized care plan.