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FUNDAMENTALS OF NURSING

ACTIVE LEARNING FOR

COLLABORATIVE PRACTICE 1ST

EDITION TEST BANK – YOOST

Chapter 08: Planning

MULTIPLE CHOICE

1. 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

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ANS: A

Use of Maslow’s hierarchy of needs helps to organize the most-urgent to less-urgent needs. This framework organizes patient data according to basic human needs common to all individuals. Maslow’s theory suggests that basic needs, such as physiologic needs,

must be met before higher needs, such as self-esteem. The first level is

“physiologic” and includes basic survival needs such as airway patency, breathing,

circulation, oxygen level, nutrition, fluid intake, body temperature regulation,

warmth, elimination, shelter, sexuality, infection, and pain level. The next level is

“safety and security” includes physical safety (prevention of falls and drug side

effects) and knowledge of routines and procedures. The level of “love and

belonging” involves the need for love and affection, including compassion from

the care provider, information from family and significant others, and strength of a

support system. “Self-esteem” refers to the need to feel good about oneself and

includes changes in body image (from injury, surgery, puberty) and changes in

self-concept.

DIF: Remembering REF: p. 107 OBJ: 8.2

TOP: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT: Concepts: Care Coordination

2. 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.

ANS: A

Setting priorities among identified nursing diagnoses is the first step in the

planning process. The nurse is responsible for monitoring patient responses, making decisions culminating in a plan of care, and implementing interventions,

including interdisciplinary collaboration and referral, as needed. The nurse is significantly accountable for achieving the desired outcomes.


TOP: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:

Management of Care


3. 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

ANS: C

It is essential that the nurse identify life-threatening concerns and patient

situations that need to be addressed most quickly. The ABCs of life support—

airway, breathing, and

circulation—are a valuable tool for directing the nurse’s thought process.

Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds. For instance, if a patient is in respiratory arrest,

the most critical goal is for the patient to begin breathing. The reddened coccyx, decreased urinary output, and surgical incision drainage are not immediately life

threatening.

DIF: Understanding REF: p. 107 OBJ: 8.2

TOP: Planning



4. Which should the nurse address first?

a. Pain

b. Hunger

c. Decreased self-esteem

d. Absence of pulse

ANS: D

It is essential that the nurse identify life-threatening concerns and patient

situations that need to be addressed most quickly. The ABCs of life support—

airway, breathing, and circulation—are a valuable tool for directing the nurse’s

thought process. Depending on

the severity of a problem, the steps of the nursing process may be performed in a matter of seconds. For instance, if a patient is in respiratory arrest, the most critical goal is for the patient to begin breathing. Pain, hunger, and decreased self-esteem are not immediately life threatening. The absence of pulse is.


TOP: Planning


Management of Care


5. 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.”

ANS: A

Planning is the third step of the nursing process. During the planning phase, the

professional nurse prioritizes the patient’s nursing diagnoses, determines short-

and long-term goals, identifies outcome indicators, and lists nursing interventions

for patient-centered care. Patients should be included in the planning process.

Involving patients in planning their care helps them to (1) be aware of identified

needs, (2) accept realistic and measurable goals, and (3) embrace interventions to

best achieve the mutually agreed-on goals. Inclusion of patients in the planning

process tends to improve goal attainment and patient cooperation with

interventions. By accepting guidance and input from patients during the planning

process, the nurse provides them with a greater sense of empowerment and

control. Depending on the patient’s condition or circumstances, it may be

advantageous to include members of the patient’s support system (i.e., family,

friends, and caregivers) in the planning phase.


TOP: Planning



6. 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.

ANS: C

Goals are broad statements of purpose that describe the aim of nursing care. Goals

represent short- or long-term objectives that are determined during the planning

step. Some sources establish time parameters for short- and long-term goals,

whereas others do not. According to Carpenito-Moyet, goals that are achievable in

less than a week are short-term goals, and goals that take weeks or months to

achieve are long-term goals. Useful and effective goals have certain

characteristics. They are mutually acceptable to the nurse, patient, and family.

They are appropriate in terms of nursing and medical diagnoses and therapy. The

goals are realistic in terms of the patient’s capabilities, time, energy, and resources,

and they are specific enough to be understood clearly by the patient and other

nurses. They can be measured to facilitate evaluation.

DIF: Understanding REF: pp. 108-109 OBJ: 8.3

TOP: Planning



7. 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.

ANS: A

The nurse creates goals with the patient and possibly with the family by discussing

the patient’s current condition, the condition to which the patient wants to

progress, and the actions the patient and nurse undertake to accomplish the goal.

The nurse’s input into this process is critical to developing reasonable goals and

interventions. Without the nurse’s guidance during this step, the goals and

interventions may be too weak to promote the patient’s success or too aggressive

for the patient to achieve. The nurse works with the patient to develop a plan of

care that is reasonable, is appropriately challenging, and promotes patient success

for goal attainment.

DIF: Applying REF: p. 109 OBJ: 8.5 TOP: Implementation


Management of Care


8. 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.

ANS: B High numbers of minority populations (particularly African American and

Hispanic) and immigrants are unable to understand health teaching. Patients of

both genders, including those who are well educated and highly literate but have

limited health care experience, may struggle with the complexity of health care

terminology and procedures. Older adults have particular problems with medical

issues when they must assimilate new information or make complex decisions

about treatments. Before implementing teaching strategies to support goal

attainment, the nurse must explore a patient’s disabilities and the effects they may

have on achieving specific goals. Successful accommodation of a patient’s

disabilities should yield attainable goals that lead to positive outcomes.

DIF: Understanding REF: p. 108 OBJ: 8.3 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:

Management of Care NOT: Concepts: Care Coordination

9. 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.

ANS: D

According to Carpenito-Moyet, goals that are achievable in less than a week are

short-term goals, and goals that take weeks or months to achieve are long-term goals. A short-term goal for a morbidly obese patient might be “Patient will lose

1 lb during 1 week’s hospitalization.” A long-term goal for this patient might be “Patient will lose 50 lb in 1 year.”

DIF: Analyzing REF: p. 109 OBJ: 8.4 TOP: Evaluation


Management of Care


10. 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.

ANS: B

Useful and effective goals have certain characteristics. They are appropriate in

terms of nursing and medical diagnoses and therapy. The goals are realistic in

terms of the patient’s capabilities, time, energy, and resources, and they are

specific enough to be understood clearly by the patient and other nurses. They

can be measured to facilitate evaluation. In option A, there is no time frame to

gauge expectations so the diagnosis is not measurable. In option C, the number

of stairs is not specified and so is not measurable. In option D, the type of

activity is not mentioned so it is not specific and there is no measurable criterion.

DIF: Analyzing REF: p. 109 OBJ: 8.4 TOP: Evaluation


Management of Care


11. 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.

ANS: A

Useful and effective goals have certain characteristics. They are mutually

acceptable to the nurse, patient, and family. They are appropriate in terms of

nursing and medical diagnoses and therapy. The goals are realistic in terms of the

patient’s capabilities, time, energy, and resources, and they are specific enough to

be understood clearly by the patient and other nurses. They can be measured to

facilitate evaluation. The nurse creates goals with the patient and possibly with the

family by discussing the patient’s current condition, the condition to which the

patient wants to progress, and the actions the patient and nurse undertake to

accomplish the goal. The nurse must consider the effects of conditions, such as

severe pain related to recent surgery or clinical depression or hopelessness, on the

ability of the patient to reach goals in a timely manner. Other barriers to goal

attainment may be related to economic issues or available resources.


TOP: Assessment


Management of Care


12. 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.

ANS: D

Patient-centered goals are written specifically for the patient. The goal should

specify the activity the patient is to exhibit or demonstrate to indicate goal

attainment. The activity may be the patient ambulating, eating, turning, coughing

and deep breathing, or any number of other activities. These goals are written to

reflect patient, not nursing, activities. Instead of focusing on the patient, the

incorrect answers focus on the patient’s temperature, the nurse medicating the

patient, and the patient’s skin integrity. Only option D focuses on the patient.


TOP: Assessment


Management of Care


13. 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.”

ANS: A Measurable goals are specific, with numeric parameters or other concrete

methods of judging whether the goal was met. When writing a goal statement

with a patient, the nurse needs to clearly identify how achievement of the goal

will be evaluated. When terms such as acceptable or normal are used in a goal

statement, goal attainment is difficult to judge because they are not measurable

terms, unless they refer to laboratory values or diagnostic test findings. The

amount of weight a patient will lift at the end of the week is not specified.

“Normal” and “acceptable” weight have not been defined.

DIF: Analyzing REF: p. 109 OBJ: 8.3 TOP: Evaluation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:

Management of Care

14. 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.

ANS: C

In most cases, goal statements need to include a time for evaluation. The time

depends on the intervention and the patient’s condition. Some goals may need to

be evaluated daily or weekly, and others may be evaluated monthly. The health

care setting affects the time of evaluation. If the goal is set during hospitalization,

the goal may need to be evaluated within days, whereas a goal set for home care

may be evaluated weekly or monthly. At the time of evaluation, the goal is

assessed for goal attainment, and new goals are set or a new evaluation date for the

same goal may be chosen if the goal is still applicable for the patient care plan.


TOP: Assessment



15. 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.

ANS: A

There are multiple formats in which to develop individualized care plans for

patients, families, and communities. Each health care agency has its own form,

including electronic formats, to facilitate the documentation of patient goals and

individualized patient-centered plans of care. All formats contain areas in which

the nurse identifies key assessment data, nursing diagnostic statements, goals,

interventions for care, and evaluation of outcomes. In many agencies and specialty

units, standardized care plans that must be individualized for each patient are

available to guide nurses in the planning process.


TOP: Assessment


Management of Care


16. Nursing interventions that originate from the physician or primary care

provider orders are:

a. dependent

b. independent

c. collaborative

d. Nursing Interventions Classifications

ANS: A

Some interventions originate from health care provider orders. These are

dependent nursing interventions. The nurse incorporates these orders into the

patient’s overall care plan by associating each with the appropriate nursing

diagnosis. The ability of nurses to enact independent interventions has expanded in

recent years, allowing nurses to initiate care that they recognize as essential in

meeting patient needs or preventing complications. Ordering heel protectors for

patients susceptible to skin breakdown and initiating preventive measures (e.g.,

activity regimens, consultations with social workers, preadmission teaching) are

often independent, nurse-initiated interventions. Collaborative interventions

require cooperation among several health care professionals and unlicensed

assistive personnel (UAP). Collaborative interventions include activities such as

physical therapy, home health care, personal care, spiritual counseling, medication

reconciliation, and palliative or hospice care. One method of determining

interventions to meet patient outcome goals is to use the Nursing Interventions

Classification (NIC), a comprehensive, research-based, standardized collection of

interventions and associated activities. NIC provides nurses with multidisciplinary

interventions linked to each NANDA-I nursing diagnosis and a corresponding

NOC.

TOP: Assessment



17. Medication administration is what type of nursing intervention?

a. Independent

b. Dependent

c. Collaborative

d. Interdisciplinary

ANS: B













reconciliation, and palliative or hospice care. One method of determining

interventions to meet patient outcome goals is to use the Nursing Interventions

Classification (NIC), a comprehensive,

research-based, standardized collection of interventions and associated activities. NIC provides nurses with multidisciplinary interventions linked to each NANDA-I nursing diagnosis and a corresponding NOC.


TOP: Assessment



18. Dependent nursing interventions include:

a. ordering heel protectors.

b. preadmission teaching.

c. medication reconciliation.

d. administer antipyretic medications as appropriate.

ANS: D

Some interventions originate from health care provider orders. These are dependent nursing interventions. The nurse incorporates these orders into the

patient’s overall care plan by associating each with the appropriate nursing diagnosis. The ability of nurses to enact independent interventions has expanded

in recent years, allowing nurses to initiate care that they recognize as essential in

meeting patient needs or preventing

complications. Ordering heel protectors for patients susceptible to skin breakdown

and initiating preventive measures (e.g., activity regimens, consultations with

social workers, preadmission teaching) are often independent, nurse-initiated

interventions. Collaborative interventions require cooperation among several

health care professionals and unlicensed assistive personnel (UAP). Collaborative

interventions include activities such as physical therapy, home health care,

personal care, spiritual counseling, medication reconciliation, and palliative or

hospice care.


TOP: Assessment



19. 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.

ANS: A













reconciliation, and palliative or hospice care. Assessment data are not considered

interventions.


TOP: Assessment



20. Discharge planning begins:

a. the day before discharge.

b. upon admission.

c. prior to admission.

d. day of discharge.

ANS: B

Discharge planning plays an important role in the success of a patient’s transition to the home setting after hospitalization. Because most patients are in

the hospital for only a short time, nurses must begin discharge planning on admission and continue until a patient is dismissed.


TOP: Assessment


Management of Care


21. 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.”

ANS: A

Research shows that comprehensive discharge planning reduces complications and

readmissions. Home care planning adapts to the situation as the patient’s condition improves or deteriorates as a result of advancing disease. Because most patients

are in the hospital for only a short time, nurses must begin discharge planning on admission and continue until a patient is dismissed.


TOP: Assessment


Management of Care


MULTIPLE RESPONSE

1. 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.

ANS: A, B, C, D

The significance of developing organized plans of care for patients cannot be

stressed enough. The nurse must take seriously the responsibility of prioritizing

patient needs, developing mutually agreed-on goals, determining outcome

criteria, and identifying interventions that can help patients to achieve positive

outcomes. After these actions are completed in the planning phase of the nursing

process, it is time for implementation of the patient’s plan of care

(Implementation phase).


TOP: Assessment


Management of Care


2. 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.

ANS: A, B, C, D

Planning is the third step of the nursing process. During the planning phase, the

professional nurse prioritizes the patient’s nursing diagnoses, determines short-

and long-term goals, identifies outcome indicators, and lists nursing interventions

for patient-centered care. Each of these actions requires careful consideration of

assessment data (collected earlier) and a thorough understanding of the

relationship among nursing diagnoses, goals, and evidence-based interventions.

DIF: Applying REF: p. 106 OBJ: 8.1 TOP: Implementation



3. 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.

ANS: A, C, D

Patients should be included in the planning process. Involving patients in planning

their care helps them to (1) be aware of identified needs, (2) accept realistic and

measurable goals, and (3) embrace interventions to best achieve the mutually

agreed-on goals. Inclusion of patients in the planning process tends to improve

goal attainment and patient cooperation with interventions. By accepting guidance

and input from patients during the planning process, the nurse provides them with

a greater sense of empowerment and control.


TOP: Planning


Management of Care


4. Measurable goals are: (Select all that apply.)

a. specific

b. concrete

c. vague

d. easy to judge

e. non-specific

ANS: A, B, D

Measurable goals are specific, with numeric parameters or other concrete

methods of judging whether the goal was met. When writing a goal statement

with a patient, the nurse needs to clearly identify how achievement of the goal

will be evaluated. When terms such as acceptable or normal are used in a goal

statement, goal attainment is difficult to judge because they are not measurable

terms, unless they refer to laboratory values or diagnostic test findings.


TOP: Assessment



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