Deck 8: Planning

Question 1

The nurse recognizes which term identifies nursing interventions that originate from the health care provider orders?

A) Dependent
B) Independent
C) Collaborative
D) Nursing interventions classifications

Answer 1

Dependent

Question 2

The nurse is caring for a patient who has undergone abdominal surgery. The patient stated prior to surgery that "I don't think I'll be able to handle this if I get a colostomy. I wouldn't know how to manage it." The patient is complaining of severe surgical pain and has an order for morphine sulfate. The nurse is correct when addressing which Nursing diagnosis first?

A) Pain
B) Alteration in body image
C) Knowledge deficit
D) Risk for falls

Answer 2

Pain

Question 3

The nurse demonstrates a thorough understanding of the planning phase of the nursing process when making which statement?

A) "Patients should be included in the planning process."
B) "Patient families should not interfere in the planning process."
C) "The planning process should focus on short-term goals only."
D) "Planning is the first phase of the nursing process."

Answer 3

"Patients should be included in the planning process."

Question 4

Which statement by the nurse is correct regarding diversity considerations?

A) The male gender may struggle less with health care terminology.
B) High numbers of minority populations do not understand health teachings.
C) Older adults understand health teaching easily because of life experience.
D) Disabilities have no impact on the development of patient care goals.

Question 5

The nurse knows which response to be an example of a measurable goal?

A) "The patient will be able to lift 10 lb. by the end of week one."
B) "The patient will be able to lift weights by the end of the week."
C) "The patient will be able to lift his normal weight amount."
D) "The patient will be able to lift an acceptable amount of weight by week one."

Question 6

The nurse is formulating the patient's care plan. In determining when to evaluate the patient's progress, the nurse is aware that evaluations should be carried out within which parameters?

A) They must be done at the end of every shift.
B) They should be done at least every 24 hours.
C) They depend on intervention and patient condition.
D) They are always done at time of discharge.

Question 7

The nurse identifies medication administration to be what type of nursing intervention?

A) Independent
B) Dependent
C) Collaborative
D) Interdisciplinary

Question 8

The nurse understands that discharge planning begins at what point in the patient's hospitalization?

A) The day before discharge
B) Upon admission
C) Prior to admission
D) Day of discharge

Question 9

The nurse is caring for a patient who has had abdominal surgery and has developed a slight temperature. The nurse identifies which statement to be a patient-centered goal?

A) The patient's temperature will return to normal within 24 hours.
B) The nurse will medicate the patient for elevated temperature every 4 hours as needed.
C) Skin integrity will be maintained until the patient is ambulatory.
D) The patient will ambulate 10 feet by postoperative day 2.

Question 10

The nurse recognizes that physical therapy, speech therapy, home health care, and personal care are examples of which type of interventions?

A) Collaborative interventions
B) Dependent nursing interventions
C) Independent nursing interventions
D) Assessment interventions

Question 11

When developing the nursing care plan, the nurse includes which concept when creating goals?

A) Develops the goals with the patient and possibly the family.
B) Creates the goals that the nurse wants the patient to achieve.
C) Includes the actions that are needed to accomplish the goal.
D) Focus on goals that are aggressive to ensure success.

Question 12

The nurse knows that standardized care plans may be available and are utilized under which circumstance?

A) They need to be individualized for each patient.
B) They are implemented without adjustment.
C) They remove the need for nurse involvement.
D) They do not require the use of Nursing diagnoses.

Question 13

Which assessment made by the nurse should be addressed first?

A) Reddened area to coccyx
B) Decreased urinary output
C) Shortness of breath
D) Drainage from surgical incision

Question 14

The nurse recognizes which is a correctly written example of a short-term goal?

A) The patient will lose 50 lb in 1 year.
B) Patient will ambulate 1 mile without shortness of breath.
C) Patient will be able to change the colostomy bag in 6 weeks.
D) The patient will eat 75% of all meals for the next three days.

Question 15

The nurse recognizes which response as a barrier to achieving goals?

A) The effects of pain and/or clinical depression
B) Patient involvement in setting patient goals
C) Family involvement in setting patient goals
D) Realistic expectations of the patient's capabilities

Question 16

Setting priorities among identified Nursing diagnoses is the first step in the planning process. The nurse knows this prioritization includes which action?

A) Monitoring patient responses
B) Carrying out the health care provider's plan of care
C) Providing all interventions
D) Collaborating with other disciplines

Question 17

The nurse recognizes which action to be a dependent nursing intervention?

A) Utilizing heel protectors
B) Preadmission teaching
C) Medication reconciliation
D) Oxygen administration via mask

Question 18

The nurse recognizes that patient goals include which characteristic?

A) They are considered short-term if achieved within a month of identification.
B) They always have established time parameters, such as "long-term" or "short-term."
C) They are mutually acceptable to the nurse, patient, and family.
D) They can be vague to facilitate flexibility when evaluating achievement.

Question 19

The nurse identifies which goal is written correctly for the Nursing diagnosis of activity intolerance related to imbalance between oxygen supply and demand?

A) Patient will walk 1 mile without shortness of breath.
B) Patient will ambulate 100 feet with no shortness of breath on third day after treatment.
C) Patient will climb stairs without shortness of breath by day 2 of hospital stay.
D) Patient will tolerate activity.

Question 20

Which patient issue should the nurse address first?

A) Pain
B) Hunger
C) Decreased self-esteem
D) Absence of pulse

Question 21

The nurse recognizes measurable goal to have which characteristics?

A) Specific
B) Concrete
C) Vague
D) Easy to judge
E) Nonspecific

Question 22

The nurse identifies which statement to be accurate regarding discharge planning?

A) "It may decrease the incidence of patients who need to return to the hospital."
B) "It increases complications and readmissions in most cases."
C) "It adapts to the situation as the patient's conditions changes."
D) "It should begin as soon as the patient is discharged home."

Question 23

Since in the planning phase, the significance of developing organized plans of care for patients is important, the nurse must take seriously which of these responsibilities?

A) Prioritizing patient needs
B) Developing mutually agreed-on goals
C) Determining outcome criteria
D) Identifying interventions
E) Implementation of the patient's plan of care

Question 24

The nurse is formulating a plan of care for a patient. In this phase of the nursing process, the nurse should complete which actions?

A) Prioritize Nursing diagnoses.
B) Determine short- and long-term goals.
C) Identify outcome indicators.
D) List nursing interventions.
E) Gather assessment data.

Question 25

The nurse recognizes that by involving the patient in planning care, which patient results occur?

A) Being aware of identified needs
B) Accepting that not all goals are measurable
C) Embracing mutually agreed-on goals
D) Feeling a sense of empowerment
E) Overcoming unrealistic goals