Chapter 18: Planning Nursing Care

Question 1

The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?

Answer 1

Planning

Question 2

A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall.
Which initial action will the nurse take next to revise the plan of care?

Answer 2

Assess the patient.

Question 3

Which information indicates a nurse has a good understanding of a goal?

Answer 3

It is a broad statement describing a desired change in a patient’s behavior.

Question 4

A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?

Answer 4

Patient will increase activity level this shift.

Question 5

The following statements are on a patient’s nursing care plan. Which statement will the nurse use as an outcome for a goal of care?

Answer 5

The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

Question 6

A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?

Answer 6

The patient will feed self at all mealtimes today without reports of shortness of breath.

Question 7

A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?

Answer 7

Reflex urinary incontinence

Question 8

The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?

Answer 8

“Begin with the highest priority diagnoses, then select appropriate interventions.”

Question 9

A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?

Answer 9

Involve the son in the plan of care as much as possible.

Question 10

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

Answer 10

Patient will have one soft, formed bowel movement by end of shift.

Question 11

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?

Answer 11

Interdependent

Question 12

A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?

Answer 12

Dependent

Question 13

Which action indicates the nurse is using a PICOT question to improve care for a patient?

Answer 13

Implements interventions based on scientific research

Question 14

A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statementRisk for loneliness related to impaired verbal communication?

Answer 14

Provide the patient with a writing board each shift.

Question 15

A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statementImpaired skin integrity related to shearing forces?

Answer 15

Turn the patient every 2 hours, even hours.

Question 16

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls?

Answer 16

Assist patient into and out of bed every 4 hours or as tolerated.

Question 17

Which action will the nurse take after the plan of care for a patient is developed?

Answer 17

Communicate the plan to all health care professionals involved in the patient’s care.

Question 18

A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take?

1. Identify the problem.
2. Discuss the findings and recommendation.
3. Provide the consultant with relevant information about the problem.
4. Contact the right professional, with the appropriate knowledge and expertise.
5. Avoid bias by not providing a lot of information based on opinion to the consultant.

Answer 18

1, 4, 3, 5, 2

Question 19

A hospital’s wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient’s dressing changes. Which action should the nurses take next?

Answer 19

Include dressing change instructions and frequency in the care plan.

Question 20

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)

a. Rank all the patient’s nursing diagnoses in order of priority.
b. Do not change priorities once they’ve been established.
c. Set priorities based solely on physiological factors.
d. Consider time as an influencing factor.
e. Utilize critical thinking.

Answer 20

A,D,E

Question 21

A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)

a. Includes seven domains for level 1
b. Uses an easy 3-point Likert scale
c. Adds objectivity to judging a patient’s progress
d. Allows choice in which interventions to choose
e. Measures nursing care on a national and international level

Answer 21

C,E