Question 1

The nurse is planning care for a patient by using a standardized care plan for Impaired Walking, related to left-side weakness. Which activity will the nurse perform when individualizing the plan for the patient?
A)Validating conflicting data with the patient
B)Transcribing medical orders
C)Stating the frequency for ambulation
D)Performing a comprehensive assessment

Accepted Answer

Stating the frequency for ambulation is a way to individualize a standardized care plan to meet the specific needs of a patient, such as determining how often the patient should practice walking based on their condition and goals.

Question 2

The nurse is providing care for a patient following a total-knee replacement. The patient is to remain in acute care for two days. When developing an individualized plan of care for this patient, which goals set by the nurse are considered to be short-term? Select all that apply.
A)Patient will ambulate 10 feet with assistance 5 hours after surgery.
B)Patient will exhibit the ability to use a walker when ambulating.
C)Patient will understand the signs of infection at the surgery site.
D)Patient will experience a pain level of 4 or below on a 0-to-10 scale.
E)Patient will voice understanding of pain management at home.

Accepted Answer

Short-term goals are those that can be achieved relatively quickly and are often set for the immediate future. In the context of a patient who has just undergone a total knee replacement and is to remain in acute care for two days, short-term goals would include activities and outcomes that can be achieved within that timeframe. - A) Ambulating 10 feet with assistance 5 hours after surgery is a specific, measurable goal that can be achieved shortly after the operation, making it a short-term goal.- B) Exhibiting the ability to use a walker when ambulating is another goal that can be achieved within the acute care period, as it involves the patient learning and demonstrating a skill necessary for their immediate mobility.- D) Experiencing a pain level of 4 or below on a 0-to-10 scale is a goal related to pain management, which is a critical aspect of post-operative care and can be addressed and achieved in the short term through medication and other pain management strategies.C) and E) are more related to patient education and understanding, which, while they can begin in the acute care setting, are considered ongoing goals that extend beyond the immediate post-operative period.

Question 3

The nurse writes a nursing diagnosis for a patient, which states, "Impaired Memory, related to fluid and electrolyte imbalances, as manifested by (AMB) inability to express knowledge of recent events." Which essential goal/outcome does the nurse include on the care plan?
A)Current medications are reviewed for mind-altering side effects.
B)Patient demonstrates using techniques to help with memory loss.
C)Oral fluid intake of at a minimum of 1,500 mL of fluid per day.
D)Electrolyte supplements will be taken, as prescribed, with meals.

Accepted Answer

The goal/outcome should directly address the nursing diagnosis of "Impaired Memory." Option B focuses on the patient demonstrating techniques to help with memory loss, which aligns with addressing the memory impairment.

Question 4

The nurse is updating a patient plan of care. Which outcome statement, written by the nurse, contains the best example of performance criteria?
A)Patient turns self in bed frequently while awake
B)Patient understands how to use crutches by day two
C)Patient states that pain is decreased after being medicated
D)Patient eats 75% of each meal without complaint of nausea

Accepted Answer

The best example of performance criteria is D) "Patient eats 75% of each meal without complaint of nausea" because it provides a specific, measurable outcome. Performance criteria should be quantifiable and clear, and this option gives a precise percentage of food intake as a goal, along with the absence of a specific symptom (nausea), making it easy to evaluate whether the goal has been met.

Question 5

The nurse is developing a plan of care for a patient following surgery, and plans to include collaborative interventions. Which definition of goal/outcome is applicable for collaborative problems?
A)Collaborative problems are monitored only by other disciplines.
B)Collaborative problems are usually affected by nursing interventions.
C)Collaborative problems state that a complication will not occur.
D)Collaborative problems state only broad performance criteria.

Accepted Answer

Collaborative problems involve potential complications that require both nursing and other healthcare professionals' interventions to prevent or manage, thus stating that a complication will not occur is applicable.

Question 6

A client arrives in the emergency department and is pale and breathing rapidly. The client immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the client and decides the first series of actions needed. Which type of planning is the nurse demonstrating?
A)Formal planning
B)Informal planning
C)Ongoing planning
D)Initial planning

Accepted Answer

The nurse is demonstrating informal planning, which is a quick and immediate form of planning based on the nurse's experience and knowledge, often used in emergency situations where immediate action is required without the time for detailed planning.

Question 7

The nurse is formulating a plan of care for an older client admitted for dehydration. The nurse develops goals from a standardized care plan and the physician's medical orders. Which nurse-sensitive goal is appropriate for this patient?
A)Ask the patient about oral fluid preferences.
B)Maintain a full water pitcher at the patient's bedside.
C)Ensure patient's oral intake is 100 mL/hour during the day.
D)Keep the patient on strict intake and output (I&O) monitoring.

Accepted Answer

A nurse-sensitive goal focuses on outcomes that are directly influenced by nursing interventions. Ensuring the patient's oral intake is 100 mL/hour during the day is a measurable goal that the nurse can directly influence and monitor.

Question 8

The nurse is working on a new nursing unit that utilizes preprinted standardized care plans along with comprehensive care plans developed by the nurse. Which is the most important advantage for the use of both types of care plans?
A)Helps ensure that important interventions for the diagnosis are not overlooked
B)May prescribe care for one or more nursing diagnosis or medical conditions
C)Includes nursing interventions along with multidisciplinary interventions
D)Promotes a consistency of care among patients with similar conditions

Accepted Answer

Using both standardized and comprehensive care plans ensures that important interventions specific to the diagnosis are not overlooked, providing a more thorough and individualized approach to patient care.

Question 9

The nurse is individualizing a client's plan of care for the nursing diagnosis Anxiety. For which reason does the nurse write goals/outcomes on the plan of care?
A)To recognize desirable changes related to formulated interventions
B)To monitor specific patient responses to medical interventions
C)To identify specific nursing behaviors to improve a patient's health
D)To utilize criteria to evaluate the appropriateness of a nursing diagnosis

Accepted Answer

Goals/outcomes on a plan of care are written to recognize desirable changes related to formulated interventions, helping to guide the nursing actions and evaluate the effectiveness of care provided in addressing the nursing diagnosis, such as Anxiety in this context.

Question 10

Newly hired nurses on an acute care unit are encouraged to utilize computerized care planning in providing patient care. Which advantages exist from this process? Select all that apply.
A)The computer stores nursing diagnoses, medical diagnoses, and individualized interventions.
B)The computer generates a diagnosis and desired outcome after the patient's assessment is entered.
C)The computer is capable of generating a list of suggested interventions, the nursing diagnosis, and goals.
D)The computer promotes the development and refinement of nursing intuition, insight, or expertise.
E)The computer prompts the nurse to consider a variety of actions and decreases overlooking common and important interventions.

Accepted Answer

The answer of Newly hired nurses on an acute care...

Question 11

The nurse is reviewing the goals set on a patient's plan of care. Which description specifically differentiates short-term goals from long-term goals? Short-term goals:
A)Can be met within a few hours or a few days.
B)Flow from the problem side of the nursing diagnosis.
C)Must have target times with dates.
D)Specify desired patient responses to interventions.

Accepted Answer

Short-term goals are designed to be achieved within a brief period, such as a few hours to a few days, distinguishing them from long-term goals which are aimed to be accomplished over a longer period.

Question 12

The nurse is working on development of a plan of care for a patient hospitalized for a respiratory infection. Which is the best example of an outcome statement for this patient?
A)Uses the incentive spirometer when awake
B)Walks two times in the hall during day and evening shift
C)Maintains oxygen saturation above 92% while performing activities of daily living (ADLs)
D)Tolerates 10 sets of range-of-motion exercises with physical therapy

Accepted Answer

An outcome statement should be specific, measurable, attainable, relevant, and time-bound (SMART). Option C, "Maintains oxygen saturation above 92% while performing activities of daily living (ADLs)," meets these criteria by specifying a measurable goal (oxygen saturation above 92%) that is directly related to the patient's condition (respiratory infection) and relevant to the patient's ability to perform ADLs.

Question 13

The nurse is creating a comprehensive patient plan of care. Which information does the nurse include?
A)Methods of performing patient activities of daily living (ADLs)
B)Both medical and nursing interventions
C)Reasons for assigning care personnel
D)Symptoms of patient's medical diagnosis

Accepted Answer

A comprehensive patient plan of care includes both medical and nursing interventions to address the patient's overall health needs and ensure coordinated care.

Question 14

The nurse asks the nurse manager, "What do initial planning, ongoing planning, and discharge planning have in common?" Which information from the nurse manager is correct?
A)They are based on assessment and diagnosis.
B)They focus on the patient's perception of needs.
C)They require input from a multidisciplinary team.
D)They have specific time lines in which to be completed.

Accepted Answer

All types of planning in nursing—initial, ongoing, and discharge—are based on assessment and diagnosis to ensure that patient care is tailored to individual needs and conditions.

Question 15

A nurse is overheard complaining about the time used to develop patients' plans of care. Which information does the nurse manager share with the nurse about the importance of the process? Select all that apply.
A)Ensures that provided care is complete
B)Supports of continuity of care among nurses and between shifts
C)Promotes the efficient use of nursing efforts and care activities
D)Provides nurses with a guide for assessment and documentation
E)Meets the requirements set by accrediting agencies regarding care

Accepted Answer

Developing patients' plans of care is crucial for several reasons: it ensures that the care provided is comprehensive and complete, supports continuity of care among nurses and between shifts, promotes the efficient use of nursing efforts and care activities, provides nurses with a structured guide for assessment and documentation, and meets the standards and requirements set by accrediting agencies regarding patient care.

Question 16

A nurse is providing care for an older adult patient of Asian heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association (ANA) standards for outcomes identification? Select all that apply.
A)Developing culturally appropriate outcomes
B)Using the standardized outcomes on the clinical pathway
C)Choosing the best outcome for the patient, regardless of the cost
D)Involving the patient and family in formulating the outcomes
E)Advocating for the patient regarding unwanted treatment or healthcare

Accepted Answer

The answer of A nurse is providing care for an...

Question 17

In which manner does the nurse understand that NANDA-I problem labels and Nursing Outcome Classification (NOC) outcome labels are alike?
A)Health status is expressed in terms of human responses.
B)Patient response is expressed before interventions are done.
C)Patient responses are always expressed in positive terms.
D)Both methods reveal patterns of related cues.

Accepted Answer

NANDA-I problem labels and NOC outcome labels both express health status in terms of human responses, focusing on how individuals respond to health conditions, treatments, or interventions.

Question 18

The nurse recognizes which client as having the greatest need for comprehensive formal discharge planning?
A)A postpartum patient after the birth to her second child, who lives with her spouse and 18-month-old daughter
B)A patient who is readmitted for exacerbation of chronic obstructive pulmonary disease (COPD)
C)A patient who is 12-years of age being discharged home with a parent after outpatient surgery
D)An adult patient just diagnosed with renal failure who is scheduled to start peritoneal dialysis

Accepted Answer

An adult patient just diagnosed with renal failure who is scheduled to start peritoneal dialysis would have the greatest need for comprehensive formal discharge planning. This is because the diagnosis of renal failure and the initiation of peritoneal dialysis involve significant lifestyle changes, require detailed education on the procedure, diet modifications, and potentially complex medication management.

Question 19

The nurse in an acute care facility is preparing to discharge an older client to an extended care facility. Which objectives does the nurse address in preparation for a comprehensive discharge process for this client? Select all that apply.
A)Maintain interagency communication
B)Determine level of family involvement
C)Share information about financial status
D)Activities for maintaining functional ability
E)Current ability for performing self-care needs

Accepted Answer

The answer of The nurse in an acute care facility...

Quiz 5: Planning Outcomes

The nurse is planning care for a patient by using a standardized care plan for Impaired Walking, related to left-side weakness. Which activity will the nurse perform when individualizing the plan for the patient?

The nurse is providing care for a patient following a total-knee replacement. The patient is to remain in acute care for two days. When developing an individualized plan of care for this patient, which goals set by the nurse are considered to be short-term? Select all that apply.

The nurse writes a nursing diagnosis for a patient, which states, "Impaired Memory, related to fluid and electrolyte imbalances, as manifested by (AMB) inability to express knowledge of recent events." Which essential goal/outcome does the nurse include on the care plan?

The nurse is updating a patient plan of care. Which outcome statement, written by the nurse, contains the best example of performance criteria?

The nurse is developing a plan of care for a patient following surgery, and plans to include collaborative interventions. Which definition of goal/outcome is applicable for collaborative problems?

A client arrives in the emergency department and is pale and breathing rapidly. The client immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the client and decides the first series of actions needed. Which type of planning is the nurse demonstrating?

The nurse is formulating a plan of care for an older client admitted for dehydration. The nurse develops goals from a standardized care plan and the physician's medical orders. Which nurse-sensitive goal is appropriate for this patient?

The nurse is working on a new nursing unit that utilizes preprinted standardized care plans along with comprehensive care plans developed by the nurse. Which is the most important advantage for the use of both types of care plans?

The nurse is individualizing a client's plan of care for the nursing diagnosis Anxiety. For which reason does the nurse write goals/outcomes on the plan of care?

Newly hired nurses on an acute care unit are encouraged to utilize computerized care planning in providing patient care. Which advantages exist from this process? Select all that apply.

The nurse is reviewing the goals set on a patient's plan of care. Which description specifically differentiates short-term goals from long-term goals? Short-term goals:

The nurse is working on development of a plan of care for a patient hospitalized for a respiratory infection. Which is the best example of an outcome statement for this patient?

The nurse is creating a comprehensive patient plan of care. Which information does the nurse include?

The nurse asks the nurse manager, "What do initial planning, ongoing planning, and discharge planning have in common?" Which information from the nurse manager is correct?

A nurse is overheard complaining about the time used to develop patients' plans of care. Which information does the nurse manager share with the nurse about the importance of the process? Select all that apply.

A nurse is providing care for an older adult patient of Asian heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association (ANA) standards for outcomes identification? Select all that apply.

In which manner does the nurse understand that NANDA-I problem labels and Nursing Outcome Classification (NOC) outcome labels are alike?

The nurse recognizes which client as having the greatest need for comprehensive formal discharge planning?

The nurse in an acute care facility is preparing to discharge an older client to an extended care facility. Which objectives does the nurse address in preparation for a comprehensive discharge process for this client? Select all that apply.