Deck 8: Planning

Question 1

The nurse knows that standardized care plans may be available and:

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

Answer 1

need to be individualized for each patient.

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." There is no "next of kin" listed in the patient's record. The patient is complaining of severe surgical pain. 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 is formulating the patient's care plan. In determining when to evaluate the patient's progress, the nurse is aware that evaluations:

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

Answer 3

depend on intervention and patient condition.

Question 4

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 5

Nursing interventions that originate from the physician or primary care provider orders are:

A) dependent
B) independent
C) collaborative
D) Nursing Interventions Classifications

Question 6

An example of a measurable goal would be:

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 life an acceptable amount of weight by week one."

Question 7

Goals are broad statements of purpose that describe the aim of nursing care. As such, goals:

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

Question 8

Physical therapy, home health care, and personal care are examples of:

A) collaborative interventions.
B) dependent nursing interventions.
C) independent nursing interventions.
D) assessment data.

Question 9

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 10

The nurse is caring for a patient who has had abdominal surgery but has developed a slight temperature. A patient-centered goal would be:

A) the patient's temperature will return to normal within 24 hours.
B) the nurse will medicate the patient for surgical pain every 4 hours.
C) skin integrity will be maintained until the patient is ambulatory.
D) the patient will ambulate 10 feet by post-op day 2.

Question 11

Which should the nurse address first?

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

Question 12

Medication administration is what type of nursing intervention?

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

Question 13

In developing the nursing care plan, the nurse creates goals:

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

Question 14

Setting priorities among identified nursing diagnoses is the first step in the planning process. The nurse is responsible for:

A) monitoring patient responses.
B) carrying out the physician's plan of care.
C) providing all interventions.
D) preventing interference from other disciplines.

Question 15

Which statement 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 have an easier time understanding health teachings because of life experience.
D) Disabilities have no impact on the development of patient care goals.

Question 16

The nurse has a thorough understanding of the planning phase of the nursing process when stating:

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."

Question 17

Discharge planning begins:

A) the day before discharge.
B) upon admission.
C) prior to admission.
D) day of discharge.

Question 18

Which of the following is a correctly written example of a short-term goal?

A) By attending the gym, the patient will lose 50 lb in 1 year.
B) In 6 months, patient will be able to ambulate 1 mile without shortness of breath.
C) Patient will be able to change his colostomy bag within 6 weeks of surgery.
D) With diet and exercise, the patient will lose 1 lb this week.

Question 19

The nurse recognizes which of the following 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 20

Dependent nursing interventions include:

A) ordering heel protectors.
B) preadmission teaching.
C) medication reconciliation.
D) administer antipyretic medications as appropriate.

Question 21

The significance of developing organized plans of care for patients cannot be stressed enough. In the planning phase, the nurse must take seriously the responsibility of: (Select all that apply.)

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 22

The nurse is accurate when stating that adequate discharge planning:

A) "May decrease the incidence of patients required to return to the hospital."
B) "Increases complications and readmissions in most cases."
C) "Adapts to the situation as the patient's conditions changes."
D) "Should begin as soon as the patient is discharged home."

Question 23

Patients should be included in the planning process. Involving patients in planning their care helps them to: (Select all that apply.)

A) be aware of identified needs.
B) accept that not all goals are measurable.
C) embrace mutually agreed-on goals.
D) feel a sense of empowerment.
E) overcome unrealistic goals.

Question 24

The nurse is formulating a plan of care for a patient. In this phase of the nursing process, the nurse: (Select all that apply.)

A) prioritizes nursing diagnoses.
B) determines short and long-term goals.
C) identifies outcome indicators.
D) lists nursing interventions.
E) gathers assessment data.

Question 25

Measurable goals are: (Select all that apply.)

A) specific
B) concrete
C) vague
D) easy to judge
E) non-specific