Chapter Nursing Diagnosis Chapter 18: Planning Nursing – Flashcards
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Completes a comprehensive database
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The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
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Focus on the patient's presenting situation.
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A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
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Ask the NAP to record the patient's vital signs before administering medications.
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After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make?
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Respirations 16
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The nurse is gathering data on a patient. Which data will the nurse report as objective data?
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The patient is apprehensive about discharge.
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A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?
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Performing a physical examination
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Which method of data collection will the nurse use to establish a patient's database?
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Perform a thorough nursing health history.
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A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information?
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Consider cultural differences during this assessment.
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While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
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Ask about the chief concerns or problems.
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A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?
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"What reasons do you think are contributing to your fatigue?"
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The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?
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Patient expectations
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A nurse is conducting a nursing health history. Which component will the nurse address?
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Ask the patient about usual sleep patterns and the onset of having difficulty resting.
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While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
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Problem-oriented assessment
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The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?
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"Validation involves comparing data with other sources for accuracy."
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Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation?
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The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.
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Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?
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Ask the patient to describe the type of reaction.
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While completing an admission database, the nurse is interviewing a patient who states "I am allergic to latex." Which action will the nurse take first?
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Ask the patient about the facial grimacing with movement.
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A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations?
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The patient's room with the door closed
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The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?
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The nurse speaks only to the patient's daughter.
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A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
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c. Patient describing excitement about discharge e. Patient's expression of fear regarding upcoming surgery
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A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
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To distinguish the nurse's role from the physician's role
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After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions?
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Acute pain
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Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?
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Impaired gas exchange related to alveolar-capillary membrane changes
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A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
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Etiology
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The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
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Diagnostic reasoning
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A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?
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Acute pain
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A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?
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Diagnosis
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The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
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Health promotion
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A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?
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Assessment
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A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error?
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Abdominal distention
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A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?
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Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed
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The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?
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Disruption of tissue integrity
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A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?
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Hemorrhage
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A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene?
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Impaired skin integrity
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A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan?
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Decreased cardiac output related to altered myocardial contractility.
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A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document?
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Developing nursing diagnoses before completing the database
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A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?
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Deficient fluid volume
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A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?
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"How many bowel movements a day have you had?"
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Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?
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"Do you feel like you need to go to the bathroom?"
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A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?
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1, 3, 4, 2, 5
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A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma 2. Writes a diagnostic label of impaired gas exchange 3. Organizes data into meaningful clusters 4. Interprets information from patient 5. Writes an etiology
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c. Impaired physical mobility related to incisional pain d. Nausea related to adverse effect of cancer medication
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A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)
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Planning
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The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process?
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Assess the patient.
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A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care?
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It is a broad statement describing a desired change in a patient's behavior.
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Which information indicates a nurse has a good understanding of a goal?
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Patient will increase activity level this shift.
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A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?
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The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of the shift
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The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care?
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The patient will feed self at all mealtimes today without reports of shortness of breath.
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A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse?
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Reflex urinary incontinence
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A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
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"Begin with the highest priority diagnoses, then select appropriate interventions."
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The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
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Involve the son in the plan of care as much as possible.
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A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do?
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Patient will have one soft, formed bowel movement by end of shift.
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A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
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Interdependent
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The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
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Dependent
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A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?
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Implements interventions based on scientific research
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Which action indicates the nurse is using a PICOT question to improve care for a patient?
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Provide the patient with a writing board each shift.
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A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statementRisk for loneliness related to impaired verbal communication?
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Turn the patient every 2 hours, even hours.
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A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statementImpaired skin integrity related to shearing forces?
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Assist patient into and out of bed every 4 hours or as tolerated
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A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention ismost appropriate for the nursing diagnostic statement Risk for falls?
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Communicate the plan to all health care professionals involved in the patient's care.
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Which action will the nurse take after the plan of care for a patient is developed?
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1, 4, 3, 5, 2
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A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take? 1. Identify the problem. 2. Discuss the findings and recommendation. 3. Provide the consultant with relevant information about the problem. 4. Contact the right professional, with the appropriate knowledge and expertise. 5. Avoid bias by not providing a lot of information based on opinion to the consultant.
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Include dressing change instructions and frequency in the care plan.
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A hospital's wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient's dressing changes. Which action should the nurses take next?
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a. Rank all the patient's nursing diagnoses in order of priority. d. Consider time as an influencing factor. e. Utilize critical thinking.
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A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.)
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c. Adds objectivity to judging a patient's progress e. Measures nursing care on a national and international level
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A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)
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Implementation
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A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse?
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Protocols assist the clinician in making decisions and choosing interventions for specific health care problem/ conditions.
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The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching?
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Administer the acetaminophen.
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The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
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Determines whether an intervention is correct and appropriate for the given situation
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Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
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Provide assistance while the patient walks in the hallway twice this shift with crutches.
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A nurse is reviewing a patient's care plan. Which information will the nurse identify as a nursing intervention?
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Administer pain medication.
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A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority?
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Assesses the patient's readiness for the procedure
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The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?
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Ask the patient to return to the room, so the nurse can inspect the abdomen.
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A patient visiting with family members in the waiting area tells the nurse "I don't feel good, especially in the stomach." What should the nurse do?
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Medicate the patient to alleviate discomfort while ambulating.
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A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
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Develop good communication skills.
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A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take?
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Reassess the patient.
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Which action should the nurse take first during the initial phase of implementation?
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Assess the patient for other symptoms or problems, and then notify the health care provider.
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Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's first action?
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Reassess the patient.
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Which initial intervention is most appropriate for a patient who has a new onset of chest pain?
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Observe wound appearance and edges.
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A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first?
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Interpersonal
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The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using?
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Psychomotor
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The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using?
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"This system can help medical students determine the cost of the care they provide to patients."
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A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided?
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Counseling about respite care options
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The nurse is intervening for a family member with role strain. Which direct care nursing intervention is mostappropriate?
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Teaches proper handwashing technique
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The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?
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2, 4, 1, 3
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The nurse is revising the care plan. In which order will the nurse perform the tasks, beginning with the first step? 1. Revise specific interventions. 2. Revise the assessment column. 3. Choose the evaluation method. 4. Delete irrelevant nursing diagnoses.
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c. Reposition a patient who is on bed rest. d. Teach a patient preoperative exercises. e. Transfer a patient to another hospital unit.
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A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.)
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a. Ambulating a patient b. Inserting a feeding tube c. Performing resuscitation e. Teaching about medications
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A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)
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a. Equipment b. Safe environment d. Assistive personnel
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A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
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a. Perform dressing changes twice a day as ordered. b. Teach the patient about signs and symptoms of infection. c. Instruct the family about how to perform dressing changes. e. Administer medications to control the patient's blood sugar as ordered.
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Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)
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Evaluation
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A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?
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Evaluation
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A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?
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"Nurses use evaluation to determine the effectiveness of nursing care."
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A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate?
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Reassess the patient's pain level in 30 minutes.
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After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient?
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Evaluate whether patient goals and outcomes have been met.
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A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient's plan of care?
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The patient is able to ambulate in the hallway with crutches.
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The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome?
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Absence of skin breakdown
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The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?
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Reassess the patient and situation.
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A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
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Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals."
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A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate?
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Measure the wound and observe for redness, swelling, or drainage.
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The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Whichpriority action will the nurse take?
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Revise the plan of care and change the dressing now.
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The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action?
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States feels better after talking with family and friends
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A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?
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Health behavior
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A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate?
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"I'll wear the blue dress. It matches my eyes."
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A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal?
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Patient correctly states names of family members in the room.
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A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion?
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Identify factors interfering with goal achievement.
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A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient?
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Lungs clear to auscultation following use of inhaler
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A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?
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Heart rate 78 beats/min on 12/3
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A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met?
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2, 1, 5, 4, 3
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A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication. 4. Administer new blood pressure medication. 5. Change goal to blood pressure less than 140/90.
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a. Observations of wound healing b. Daily blood pressure measurements c. Findings of respiratory rate and depth e. Patient's subjective report of feelings about a new diagnosis of cancer
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A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient's responses to nursing care? (Select all that apply.)
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b. Determine whether outcomes or standards are met. d. Document results of goal achievement. e. Use self-reflection and correct error
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Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)
