ch 8 Planning Flashcards
For a patient scheduled for knee surgery, which statement identifies when the planning step of the nursing process begins?
- After the surgery is complete
- When the patient is admitted to the hospital
- Just before being discharged from the hospital
- When the nurse contacts the patient to schedule surgery
When the nurse contacts the patient to schedule surgery
Match the nursing diagnosis to its prioritization.
Impaired Tissue Integrity:
- Life-threatening
- Clinically urgent
- Routine
Clinically urgent
Match the nursing diagnosis to its prioritization.
Impaired Sleep:
- Life-threatening
- Clinically urgent
- Routine
Routine
Match the nursing diagnosis to its prioritization.
Impaired Airway Clearance:
- Life-threatening
- Clinically urgent
- Routine
Life-threatening
Which nursing diagnosis would be ranked as the highest priority?
- Constipation
- Pressure Ulcer
- Impaired Gas Exchange
- mpaired Tissue Integrity
Impaired Gas Exchange
Which statement is an example of a long-term patient goal?
- Dress independently within 6 months.
- Demonstrate deep-breathing techniques by end of shift.
- Report an increase in appetite within 1 week.
- Identify interventions to reduce risk for infection in 2 days.
Dress independently within 6 months.
When a patient who needs to lose 60 lb (27 kg) wants to change the nurse’s recommended goal from exercising for 30 minutes a day, four times per week to exercising for 15 minutes per day, two times a week, which action would the nurse take?
- Ask why the patient does not want to lose weight.
- Allow the patient to set any goal the patient wants.
- Tell the patient the goal will not work.
- Discuss personal factors influencing the patient’s perspective.
Discuss personal factors influencing the patient’s perspective.
Which action would the nurse implement to promote patient success through goal attainment?
- Ask what the patient would like to achieve.
- Identify the goal, and tell the patient what it is.
- Tell the patient the goal was ordered by the health care provider.
- Identify one goal reflecting the nurse’s priority and another that reflects the patient’s priority.
Ask what the patient would like to achieve.
Which role would the nurse associate with selection of interventions during the planning step of the nursing process?
- Validation of nursing diagnoses
- Evaluation of the patient’s goal attainment
- Facilitation of clear communication of patient needs
- Assistance for the patient in achieving goals and improving health
Assistance for the patient in achieving goals and improving health
Which strategies would the nurse use to promote individualization of the identified nursing interventions?
- Consider patient assessment findings.
- Ensure interventions align with patient acceptance.
- Consult other professionals involved in the patient’s care.
- Consider the underlying etiology and related factors.
- Select interventions based on experience with other patients.
- Consider patient assessment findings.
- Ensure interventions align with patient acceptance.
- Consult other professionals involved in the patient’s care.
- Consider the underlying etiology and related factors.
Place the components of the planning step of the nursing process in the correct order.
- Select interventions.
- Create a plan of care.
- Prioritize nursing diagnoses.
- Establish goals and outcomes.
- Prioritize nursing diagnoses.
- Establish goals and outcomes. - Select interventions.
- Create a plan of care.
Which rationale supports the use of a conceptual care map (CCM) to develop a plan of care?
- Provides criteria for the selection of interventions
- Assists with the development of a standardized plan of care
- Lists all of the patient’s medical history in a concise format
- Provides a quick, yet comprehensive, overview of the patient’s status and plan
Provides a quick, yet comprehensive, overview of the patient’s status and plan
Match the component of the plan of care with the related information.
Nursing diagnosis:
- Heart rate (HR) 34 beats/min
- Impaired Cardiac Function, supported by bradycardia
- HR will return to 60 to 90 beats/min in 48 hours; monitor cardiac rhythm continuously
- HR 70 to 79 beats/min × 48 hours; goal met; discontinue goal
Impaired Cardiac Function, supported by bradycardia
Match the component of the plan of care with the related information.
Evaluation:
- Heart rate (HR) 34 beats/min
- Impaired Cardiac Function, supported by bradycardia
- HR will return to 60 to 90 beats/min in 48 hours; monitor cardiac rhythm continuously
- HR 70 to 79 beats/min × 48 hours; goal met; discontinue goal
HR 70 to 79 beats/min × 48 hours; goal met; discontinue goal
Match the component of the plan of care with the related information.
Key assessment data:
- Heart rate (HR) 34 beats/min
- Impaired Cardiac Function, supported by bradycardia
- HR will return to 60 to 90 beats/min in 48 hours; monitor cardiac rhythm continuously
- HR 70 to 79 beats/min × 48 hours; goal met; discontinue goal
Heart rate (HR) 34 beats/min
