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There are three different aspects of the planning process. These three phases include which of thefollowing?
a. Interventions, outcomes, and evaluation
b. Collaboration of health officials, management of care, and implementation
c. The care plan, interventions, and outcomes
d. Initial planning, ongoing planning, and discharge planning
Rationale: There are three different aspects of the planning process. These threephases include initial planning, ongoing planning, and discharge planning.
The individualized care plan is client focused. What makes it unique from a standardized care plan?
a. It has a plan for all clients with the same disease processes
.b. It is client centered
.c. It is made so all caregivers work toward the same outcomes for the client.
d. It addresses all disease processes of the client.
Rationale: The individualized care plan is client focused. What makes it uniquefrom a standardized care plan is that it is made so all caregivers work toward thesame outcomes for the client.
An agency might have a standard of care for which of the following?
A. Having laboratory obtain blood glucose if bedside blood glucose exceeds 400
B. Congestive heart failure
C. Deficient Fluid Volume
D. Rotation of sites for insulin administration
A.Rationale: Standards of care describe nursing actions for clients with specificmedical conditions and describe achievable, appropriate nursing care.Congestive heart failure is a medical condition, and many patients with thisdiagnosis have similar interventions that would be appropriate. Examples of policyand procedure or protocols are not medical conditions, they are not standards ofcare. Deficient Fluid Volume is an example of a standardized care plan based on anursing diagnosis, not a standard of care that refers to a medical problem.
(this multiple choice question has been scrambled)
The nurse instructs the client on turning, coughing, and deep breathing q 2 hours. What is therelationship of nursing interventions to problem status
?a. Health promotion interventions
b. Treatment interventions
c. Prevention interventions
d. Observation interventions
Rationale: Prevention interventions prescribe the care needed to avoidcomplications or reduce risk factors.
When writing a care plan, a nurse may use which method to assist in prioritizing?
a. Maslow’s hierarchy of needs
b. Roy’s model
c. The most important disease process that the client is experiencing
d. Orem’s model
Rationale: Nurses frequently use Maslow’s Hierarchy of Needs toprioritize their care plans.
Assessment of a client two days after surgery reveals a dressing that is dry and intact, temperature 100.2, pulse 90, and blood glucose level of 428. The client requests additional juice or water due to avery dry mouth, and says he is feeling weak and having pain with ambulation. Which of the following isthe nurse likely to consider the highest priority for a change in the plan of care?
a. Elevated blood sugar
b. Dry mouth
d. Elevated temperature
Rationale: Urgency determines the priority in planning care. In this case, theblood sugar is very high, and needs immediate intervention. Pain will need to beaddressed, but other symptoms the client is experiencing may abate once the bloodsugar is in normal range. A slightly elevated temperature is considered normalafter surgery, and with a dressing that is dry and intact, the possibility of infectionis not of the highest priority. There is no indication of the severity of the pain. Thenurse will want to further assess pain after the blood sugar is regulated. Dry mouthis likely a sign of an elevated blood sugar
The care plan includes a nursing intervention “4/2/07 Measure client’s fluid intake and output. F.Jenkins, RN.” What element of a proper nursing intervention has been omitted?
a. Action verb
Rationale: Although there may be standard policies or routines formeasuring intake and output, the nursing intervention should specify ifthis is to be done “routinely” or at specific intervals (e.g., q4h). The nurse isalso aware, however, that critical thinking indicates that the intake andoutput should be monitored more frequently than ordered if assessmentreveals abnormal findings.
A client has a nursing diagnosis of Bathing/Hygiene Self-Care Deficit related to left-sided weaknessmanifested by inability to get in and out of the bathroom, inability to wash hands or face, and fatigue.An appropriate goal for this client would be that the client:
a. Demonstrate an ability to wash face independently by 9/1/07.
b. Demonstrate a greater interest in self-care and bathing by 9/1/07.
c. Attend occupational therapy once daily to focus on left arm movement
.d. Have a nursing assistant bathe the client once daily
Rationale: Goals are written in terms of client responses, not nurseactivities. Goals must be realistic and compatible with therapies (ifprescribed). The goals should flow from the nursing diagnoses and bemeasurable. “Demonstrate a greater interest in self-care and bathing by9/1/07” is not measurable; therefore, it is not appropriate. Have a nursingassistant bathe the client once daily is what the nurse will do; it is notstated in client terms. “Attend occupational therapy once daily to focus onleft arm movement” is a client activity, but it does not have a measurableoutcome for the nurse to evaluate.
The purpose of the Nursing Outcome Classification for the nurse making a care plan is to:
a. Diagnosis of a client’s problem
.b. Set priorities.
c. Put interventions into action.
d. Measure desired outcomes and evaluation of client progress.
Rationale: The purpose of the Nursing Outcome Classification for the nursemaking a care plan is to be able to measure desired outcomes and evaluation ofclient progress.
Each outcome or goal should address
:a. Prioritiy according to outcomes.
b. The client’s main diagnosis
.c. Only one nursing diagnosis
.d. More than one purpose.
Rationale: Each outcome or goal should address only one nursing diagnosis.