Fundamentals: Chapter 18

Question 1

When does a nurse begin planning?

Answer 1

After identification of the patient’s nursing diagnosis and collaborative problems

Question 2

What does planning involve?

Answer 2

setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions

Question 3

What is the term for the ordering of nursing diagnosis or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions?

Answer 3

priority setting

Question 4

What are the classifications of a patient’s priorities?

Answer 4

High

Intermediate

Low

Question 5

Which diagnosis have a high priority?

Answer 5

if untreated, result in harm to patient or others

Question 6

Which diagnosis have an intermediate priority?

Answer 6

involve non-emergent, non life-threatening needs of patient

Question 7

Which diagnosis have a low priority?

Answer 7

affect the patient’s future well-being

Question 8

What is a “cognitive shift”?

Answer 8

shifting of attention from one patient to another during the conduct of the nursing process

Question 9

What two factors does a nurse determine during planning in order to provide a clear focus for the type of intervention needed to care for your patient and to then evaluate the effectiveness of these interventions?

Answer 9

Goal

Expected outcome

Question 10

What is a broad statement that describes a desired change in a patient’s condition of behavior?

Answer 10

Goal

Question 11

What is a measurable criterion to evaluate goal achievement?

Answer 11

Expected outcome

Question 12

What kind of knowledge does a nurse apply to plan patient care?

Answer 12

medical

sociobehavioral

nursing science

Question 13

What is a patient-centered goal?

Answer 13

reflects a patient’s highest possible level of wellness and independence in function

Question 14

What is a short-term goal?

Answer 14

an objective behavior or response that you expect a patient to achieve in a short time (usually < week)

Question 15

What is a long-term goal?

Answer 15

an objective behavior or response that you expect a patient to achieve over a longer period of time (weeks, months etc)

Question 16

How do expected outcomes direct nursing care?

Answer 16

they are the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of a patient’s health problems

Question 17

What is a measurable patient, family/community state, behavior, or perception that is largely influenced by and sensitive to nursing interventions?

Answer 17

nursing-sensitive patient outcome

Question 18

What are the 7 guidelines for writing goals and expected outcomes?

Answer 18

1. Patient-Centered
2. Singular Goal/Outcome
3. Observable
4. Measurable
5. Time-Limited
6. Mutual Factors
7. Realistic

Question 19

What kind of terms are best used to evaluate/measure outcomes precisely? (5)

Answer 19

Quality

Quantity

Frequency

Length

Weight

Question 20

Which three areas must a nurse be competent in when choosing suitable nursing interventions?

Answer 20

Knowing the scientific rational for the intervention

Possessing the necessary psychomotor and interpersonal skills

Being able to function within a particular setting to use the available health care resources effectively

Question 21

What are independent nursing interventions?

Answer 21

actions that a nurse initiates (do not require an order)

Question 22

What do independent nursing interventions pertain to?

Answer 22

ADLs, health education and promotion, and counseling

Question 23

What are dependent nursing interventions?

Answer 23

actions that a physician initiates (requires an order)

Question 24

What are collaborative interventions?

Answer 24

therapies that require the combined knowledge, skill, and expertise of multiple health care professionals

Question 25

What are the six factors to consider when choosing interventions?

Answer 25

1. Characteristics of the nursing Dx
2. Goals and expected outcomes
3. Evidence base for the intervention
4. Feasibility of the intervention
5. Acceptability to patient
6. Your own competency

Question 26

What are the 3 levels of the Nursing Interventions Classification (NIC) model?

Answer 26

Domains (broad terms)

Classes (30 clinical categories)

Interventions (542 clinical interventions)

Question 27

What is a plan of care that includes nursing diagnosis, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation finding so any nurse is able to quickly identify a patient’s clincal needs and situation?

Answer 27

nursing care plan

Question 28

Why is a nursing care plan important?

Answer 28

reduces the risk for incomplete, incorrect, or inaccurate care

Question 29

How does a nursing care plan enhance continuity of care?

Answer 29

lists specific nursing interventions needed to achieve the goals of care

Question 30

What are patient care management plans that provide the multidisciplinary health care team with the activities and tasks to be put into practice sequentially/

Answer 30

critical pathways

Question 31

What is a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or the planning and implementation of therapies?

Answer 31

Consultation