Week 4 Sherpath Flashcards
Which actions are involved in the planning step of the nursing process?
Select all that apply.
Assessing the patient
Prioritizing nursing diagnoses
Developing patient-centered goals
Creating a personalized plan of care
Evaluating the patient’s response to interventions
Prioritizing nursing diagnoses
Developing patient-centered goals
Creating a personalized plan of care
At which point would the nurse begin the planning stage of the nursing process?
At patient discharge
When the patient requires care
When the patient and nurse first interact
Upon patient admission to the hospital
When the patient and nurse first interact
Which type of planning would the office nurse perform when contacting a patient with information about what to expect before, during, and after a scheduled surgery?
Discharge planning
Home care planning
Preadmission planning
Inpatient care planning
Preadmission planning
Which goal is an example of a long-term goal for the patient?
The patient will achieve wound healing in 3 weeks.
The patient will have a pain level of less than 3 for 48 hours.
The patient will demonstrate an increase in activity tolerance in 1 week.
The patient’s wound will decrease in dimension in 2 days.
The patient will achieve wound healing in 3 weeks.
Which duration reflects an appropriate time frame for achievement of a short-term goal?
1 week
2 weeks
1 month
6 months
1 week
Which rationale explains the importance of outcome identification to the achievement of patient goals?
Determines goal validity
Indicates goal attainment
Standardizes patient goals
Tells the nurse which goals to measure
Indicates goal attainment
If the nurse collaborates with the patient when setting goals, which behaviors is the patient more likely to demonstrate?
Select all that apply.
Be aware of priority needs.
Accept realistic goals.
Allow the nurse to control care.
Be more successful in achieving goals.
Comply with interventions and behavior changes.
Be aware of priority needs.
Accept realistic goals.
Be more successful in achieving goals.
Comply with interventions and behavior changes.
Which statement about nursing interventions is accurate?
Interventions are another term for health care provider orders.
The nurse selects standardized interventions to promote safety.
Interventions are activities that assist the patient in achieving goals.
The nurse and the health care provider select the appropriate interventions for the patient.
Interventions are activities that assist the patient in achieving goals.
Which components would the nurse include in a comprehensive plan of care?
Select all that apply.
Evaluation
Interventions
Measurable goals
Medical diagnosis
Nursing diagnosis
Evaluation
Interventions
Measurable goals
Nursing diagnosis
Which part of the plan of care contains the statement, “Patient will display complete healing of surgical area within 3 weeks”?
Evaluation
Interventions
Measurable goal
Nursing diagnosis
Measurable goal
Which statement describes the plan of care?
Development of the plan of care is the first component in the planning step of the nursing process.
The Joint Commission requires the plan of care to be part of the electronic health record.
The plan of care summarizes the patient’s condition, goals, and planned interventions.
The plan of care is most effective when standardized to incorporate evidence-based practice.
The plan of care summarizes the patient’s condition, goals, and planned interventions.
Which information would the nurse expect to find on a conceptual care map (CCM)?
Select all that apply.
Medications
Pathophysiology
Medical history
Health care provider orders
Nursing plan of care
Medications
Medical history
Health care provider orders
Nursing plan of care
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.
Life-threatening
Clinically urgent
Routine
Answered choices
Impaired Airway Clearance
Impaired Sleep
Impaired Tissue Integrity
Life-threatening
Impaired Airway Clearance
Clinically urgent
Impaired Tissue Integrity
Routine
Impaired Sleep
Which nursing diagnosis would be ranked as the highest priority?
Constipation
Pressure Ulcer
Impaired Gas Exchange
Impaired 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?
Select all that apply.
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.
Create a plan of care.
Prioritize nursing diagnoses.
Select interventions.
Establish goals and outcomes.
Prioritize nursing diagnoses.
Establish goals and outcomes.
Select interventions.
Create a plan of care
