Question 1

One of the interventions for a client with a nursing diagnosis of "Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times". The modifier in this intervention is which of the following?

Accepted Answer

The modifier in the intervention is "60 to 90 degrees during feeding times" as it specifies the degree and timing of the positioning.

Question 2

A client with Parkinson's disease is working to improve fine motor skills, especially for completing activities of daily living. Which of the following would be considered a collaborative intervention?

Accepted Answer

Providing assistive devices and educating the client on how to use them is a collaborative intervention as it involves working together with the client to improve their fine motor skills. Administering medication, ensuring adequate lighting and space, and providing assistance with daily tasks are all interventions that can be done independently by the therapist without collaboration from the client.

Question 3

A student nurse is working on a care plan for an assigned client. One of the interventions the student nurse would like to include in the plan is to assist the client with ambulation. Which of the following is the best way to state this plan?

Accepted Answer

This option is the most specific and detailed intervention. It includes the use of a gait belt for safety and specifies the frequency and duration of the ambulation sessions. Option A is not as specific or detailed, and Option C is too vague. Option D is important, but is not a specific intervention for assisting with ambulation.

Question 4

Implementing nursing interventions may require the Registered Nurse to delegate particular functions within a care plan. Which of the following functions is not to be delegated?

Accepted Answer

Responsibility for total nursing care cannot be delegated as it is the ultimate responsibility of the Registered Nurse. The other options listed are tasks that can be delegated to other members of the healthcare team.

Question 5

When delegating nursing care to an unlicensed person, the Registered Nurse should:

Accepted Answer

When delegating nursing care to an unlicensed person, the RN should consider interventions based on sound judgment and knowledge of the client. An RN can delegate certain tasks to unlicensed assistive personnel (UAP) under certain criteria, but the RN remains responsible for any delegation decisions made. The RN should ensure that the care is provided safely and competently, and should evaluate the care autonomously. The RN should help the UAP choose activities that are individualised to the client, but should not transfer responsibility for the client's care to the UAP.

Question 6

A nurse is working with a client who has a diagnosis of "Impaired skin integrity, related to immobility, secondary to neurologic dysfunction". Of the following listed, which would be considered an observation intervention?

Accepted Answer

Providing ongoing assessment for skin breakdown is an observation intervention as it involves closely monitoring the client's skin for any signs of breakdown or damage. The other interventions listed involve physically taking action to prevent or treat skin breakdown.

Question 7

A client is on a regular surgical unit following a knee repair. When caring for the client, the nurse performs independent as well as dependent interventions. Which of the following is an example of a dependent intervention?

Accepted Answer

Dependent interventions are those that require a healthcare provider's order, such as administering medications. Independent interventions are those that the nurse can carry out without an order, such as repositioning and physical assessments. Assisting with transfers may be either dependent or independent, depending on the client's specific needs and their healthcare provider's orders.

Question 8

A nurse is devising a care plan for a client with complex health issues and current acute health problems. Nursing interventions must meet which of the following criteria?

Accepted Answer

Nursing interventions must always be congruent with the client's values, beliefs, and culture to ensure that the care plan is patient-centered and individualized. The interventions must be within established standards of care to ensure that the care provided is safe and effective. Additionally, the interventions must be achievable with the resources available to the nurse and the healthcare facility to ensure that the care plan is feasible and can be implemented. All of these criteria are essential for the development of a care plan that meets the needs of the client and promotes positive outcomes.

Question 9

A child is admitted to the hospital for complications from diabetes. Why is it important to keep the goal statement related to the diagnosis?

Accepted Answer

Keeping the goal statement related to the diagnosis ensures that planned nursing interventions are clearly related to the diagnosis, which increases the chances of achieving the desired outcomes. It helps in focusing the nursing care on the specific needs of the child and prevents any deviation from the primary goal of managing diabetes-related complications. The other options do not accurately reflect the importance of keeping the goal statement related to the diagnosis.

Quiz 14: Planning