TB Ch:18 - Planning Nursing Care Flashcards
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?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
ANS: C
After identifying a patient’s nursing diagnoses and collaborative problems, a nurse prioritizes the diagnoses, sets patient-centered goals and expected outcomes, and chooses nursing interventions appropriate for each diagnosis. This is the third step of the nursing process, planning. The assessment phase of the nursing process involves gathering data. The implementation phase involves carrying out appropriate nursing interventions. During the evaluation phase, the nurse assesses the achievement of goals and effectiveness of interventions.
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?
a. Consult physical therapy.
b. Establish a new plan of care.
c. Set new priorities for the patient.
d. Assess the patient.
ANS: D
Nurses revise a plan when a patient’s status changes; assessment is the first step. Know also that a plan of care is dynamic and changes as the patient’s needs change. Asking physical therapy to assist the patient is premature before assessing the patient and awaiting the health care provider’s orders. The nurse may not need to disregard all previous diagnoses. Some diagnoses may still apply, but the patient needs to be assessed first. Setting new priorities is not recommended before assessment and establishing diagnoses.
Which information indicates a nurse has a good understanding of a goal?
a. It is a statement describing the patient’s accomplishments without a time restriction.
b. It is a realistic statement predicting any negative responses to treatments.
c. It is a broad statement describing a desired change in a patient’s behavior.
d. It is a measurable change in a patient’s physical state.
ANS: C
A goal is a broad statement that describes a desired change in a patient’s condition or behavior. A goal is mutually set with the patient. An expected outcome is the measurable changes (patient behavior, physical state, or perception) that must be achieved to reach a goal. Expected outcomes are time limited, measurable ways of determining if a goal is met.
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?
a. Patient will increase activity level this shift.
b. Patient will turn side to back to side with assistance every 2 hours.
c. Patient will use the walker correctly to ambulate to the bathroom as needed.
d. Patient will use a sliding board correctly to transfer to the bedside commode as needed.
ANS: A
A goal is a broad statement of desired change; the patient will increase activity level is a broad statement. Turning is the expected outcome. When determining goals, the nurse needs to ensure that the goal is individualized and realistic for the patient. Since the patient is on bed rest, using a walker and bedside commode is contraindicated.
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?
a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.
b. The patient will demonstrate increased tolerance to activity over the next month.
c. The patient will understand needed dietary changes by discharge.
d. The patient will demonstrate increased mobility in 2 days.
ANS: A
An expected outcome is a specific and measurable change that is expected as a result of nursing care. Verbalizing decreased pain on a 0 to 10 scale is an outcome. The other three options in this question are goals. Demonstrating increased mobility in 2 days and understanding necessary dietary changes by discharge are short-term goals because they are expected to occur in less than a week. Demonstrating increased tolerance to activity over a month-long period is a long-term goal because it is expected to occur over a longer period of time.
A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?
a. The patient will ambulate in hallways.
b. The nurse will monitor the patient’s heart rhythm continuously this shift.
c. The patient will feed self at all mealtimes today without reports of shortness of breath.
d. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort.
ANS: C
An expected outcome should be patient centered; should address one patient response; should be specific, measurable, attainable, realistic, and timed (SMART approach). The statement “The patient will feed self at all mealtimes today without reports of shortness of breath” includes all SMART criteria for goal writing. “The patient will ambulate in hallways” is missing a time limit. Administering pain medication and monitoring the patient’s heart rhythm are nursing interventions; they do not reflect patient behaviors or actions.
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?
a. Risk for impaired skin integrity
b. Risk for infection
c. Spiritual distress
d. Reflex urinary incontinence
ANS: D
Reflex urinary incontinence is highest priority. If a patient’s incontinence is not addressed, then the patient is at higher risk of impaired skin integrity and infection. Remember that the Risk for diagnoses are potential problems. They may be prioritized higher in some cases but not in this situation. Spiritual distress is an actual diagnosis, but the adverse effects that could result from not assisting the patient with urinary elimination take priority in this case.
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?
a. “Choose all the interventions and perform them in order of time needed for each one.”
b. “Make sure you identify the scientific rationale for each intervention first.”
c. “Decide on goals and outcomes you have chosen for the patients.”
d. “Begin with the highest priority diagnoses, then select appropriate interventions.”
ANS: D
Work from your plan of care and use patients’ priorities to organize the order for delivering interventions and organizing documentation of care. When developing a plan of care, the nurse needs to rank the nursing diagnoses in order of priority, then select appropriate interventions. Choosing all the interventions should take place after ranking of the diagnoses, and interventions should be prioritized by patient needs, not just by time. The chosen interventions should be evidence based with scientific rationales, but the diagnoses need to be prioritized first to prioritize interventions. Goals for a patient should be mutually set, not just chosen by the nurse.
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?
a. Individualize the care plan only according to the patient’s needs.
b. Request that the son leave at bedtime, so the patient can rest.
c. Suggest that a female member of the family stay with the patient.
d. Involve the son in the plan of care as much as possible.
ANS: D
The family is often a resource to help the patient meet health care goals. Family should be included in the plan of care as much as possible. Meeting some of the family’s needs as well as the patient’s needs will possibly improve the patient’s level of wellness. The son should not be asked to leave if at all possible. In some situations, it may be best that family members not remain in the room, but no evidence in the question stem suggests that this is the case in this situation. The suggestion of asking a female member to stay is not a justified action without a legitimate reason. No reason is given in this question stem for such a suggestion.
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?
a. Patient will have one soft, formed bowel movement by end of shift.
b. Patient will walk unassisted to bathroom by the end of shift.
c. Patient will be offered laxatives or stool softeners this shift.
d. Patient will not take any pain medications this shift.
ANS: A
The identified problem, or nursing diagnosis, is constipation. Therefore, the outcome should be that the constipation is relieved. To measure constipation relief, the nurse will be observing for the patient to have a bowel movement. During planning, you select goals and expected outcomes for each nursing diagnosis or problem to provide clear direction for the type of interventions needed to care for your patient and to then evaluate the effectiveness of these interventions. Not taking pain medications may or may not relieve the constipation. Although not taking pain medicines might be an intervention, the nurse doesn’t want the patient to be in pain to relieve constipation. Other measures, such as administering laxatives or stool softeners, might be appropriate interventions but they are not outcomes. The patient walking unassisted to the bathroom addresses mobility, not constipation. The patient may need to walk to the bathroom to have a bowel movement, but the appropriate outcome for constipation is that the constipation is relieved as evidenced by a bowel movement—something that the nurse can observe.
The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
a. Dependent
b. Independent
c. Interdependent
d. Physician-initiated
ANS: C
Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals. Health care provider-initiated (HCP) interventions are dependent nursing interventions, or actions that require an order from the HCP. Nurse-initiated interventions are the independent nursing interventions, or actions that a nurse initiates without supervision or direction from others.
A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?
a. Collaborative
b. Independent
c. Interdependent
d. Dependent
ANS: D
The nurse does not have prescriptive authority to order pain medications, unless the nurse is an advanced practice nurse. The intervention is therefore dependent. Administering a medication, implementing an invasive procedure (e.g., inserting a Foley catheter, starting an intravenous [IV] infusion), and preparing a patient for diagnostic tests are examples of health care provider-initiated interventions. A collaborative, or an interdependent, intervention involves therapies that require combined knowledge, skill, and expertise from multiple health care professionals. Nurse-initiated interventions are the independent nursing interventions, or actions that a nurse initiates without supervision or direction from others.
Which action indicates the nurse is using a PICOT question to improve care for a patient?
a. Practices nursing based on the evidence presented in court
b. Implements interventions based on scientific research
c. Uses standardized care plans for all patients.
d. Plans care based on tradition
ANS: B
The best answer is implementing interventions based on scientific research. Using results of a literature search to a PICOT question can help a nurse decide which interventions to use. Practicing based on evidence presented in court is incorrect. Practice is based on current research. Using standardized care plans may be one example of evidence-based practice, but it is not used on all patients. The nurse must be careful in using standardized care plans to ensure that each patient’s plan of care is still individualized. Planning care based on tradition is incorrect because nursing care should be based on current research.
A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication?
a. Provide the patient with a writing board each shift.
b. Obtain an interpreter for the patient as soon as possible.
c. Assist the patient in performing swallowing exercises each shift.
d. Ask the family to provide a sitter to remain with the patient at all times.
ANS: A
Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. If the etiology is impaired verbal communication, then the nurse should choose an intervention that will address the problem. Providing the patient with a writing board will allow the patient to communicate by writing because the patient is unable to communicate verbally at this time. Obtaining an interpreter might be an appropriate intervention if the patient spoke a foreign language. Assisting with swallowing exercises will help the patient with swallowing, which is a different etiology than impaired verbal communication. Asking the family to provide a sitter at all times is many times unrealistic and does not relate to the impaired verbal communication; the goal would relate to the loneliness.
A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
a. Administer pain medication every 4 hours as needed.
b. Turn the patient every 2 hours, even hours.
c. Monitor vital signs, especially rhythm.
d. Keep the bed side rails up at all times.
ANS: B
The most appropriate intervention for the diagnosis of Impaired skin integrity is to turn the patient. Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. The other options do not directly address the shearing forces. The patient may need pain medication, but Acute pain would be another nursing diagnosis. Monitoring vital signs does not have when or how often these should be done. Keeping the side rails up addresses safety, not skin integrity.
