Test bank for fundamentals of nursing active learning for collaborative practice 1st edition by yoost

http://getbooksolutions.com Link full download:https://getbooksolutions.com/download/test-bank-forfundamentals-of-nursing-active-learning-for-collaborative-practice-1st-edition-byyoost Fundamentals of Nursing Active Learning for Collaborative Practice 1st Edition Test Bank – Yoost Chapter 08: Planning MULTIPLE CHOICE 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 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, http://getbooksolutions.com 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 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 http://getbooksolutions.com 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 DIF: Remembering REF: p 107 OBJ: 8.1 TOP: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 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 http://getbooksolutions.com 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 MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 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 http://getbooksolutions.com 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 DIF: Understanding 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 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 http://getbooksolutions.com 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 longterm goals, identifies outcome indicators, and lists nursing interventions for patientcentered 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 DIF: Understanding REF: p 106 OBJ: 8.2 TOP: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 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 “longterm” or “short-term.” c are mutually acceptable to the nurse, patient, and family http://getbooksolutions.com 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 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: TOP: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 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 8.3 http://getbooksolutions.com 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 MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination Which statement is correct regarding diversity considerations? a The male gender may struggle less with health care terminology b High numbers of minority populations not understand health teachings http://getbooksolutions.com 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 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 year http://getbooksolutions.com b In months, patient will be able to ambulate mile without shortness of breath c Patient will be able to change his colostomy bag within weeks of surgery d With diet and exercise, the patient will lose lb this week ANS: D According to Carpenito-Moyet, goals that are achievable in less than a week are shortterm goals, and goals that take weeks or months to achieve are long-term goals A shortterm goal for a morbidly obese patient might be “Patient will lose lb during week’s hospitalization.” A long-term goal for this patient might be “Patient will lose 50 lb in year.” DIF: Analyzing REF: p 109 OBJ: 8.4 TOP: Evaluation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 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 mile without shortness of breath http://getbooksolutions.com a the patient’s temperature will return to normal within 24 hours b the nurse will medicate the patient for surgical pain every hours c skin integrity will be maintained until the patient is ambulatory d the patient will ambulate 10 feet by post-op day 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 DIF: Understanding REF: p 109 OBJ: 8.5 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination http://getbooksolutions.com 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 NOT: Concepts: Care Coordination http://getbooksolutions.com 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 DIF: Remembering REF: p 109 OBJ: 8.4 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination http://getbooksolutions.com 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 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 DIF: Remembering REF: p 110 OBJ: 8.5 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination http://getbooksolutions.com 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 DIF: Remembering REF: p 112 OBJ: 8.6 http://getbooksolutions.com TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 17 Medication administration is what type of nursing intervention? a Independent b Dependent c Collaborative d Interdisciplinary ANS: B 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, http://getbooksolutions.com 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 DIF: Remembering REF: p 112 OBJ: 8.6 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 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 http://getbooksolutions.com 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 DIF: Remembering REF: p 112 OBJ: 8.6 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 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 http://getbooksolutions.com 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 Assessment data are not considered interventions DIF: Remembering REF: p 112 OBJ: 8.6 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 20 Discharge planning begins: a the day before discharge b upon admission c prior to admission d day of discharge http://getbooksolutions.com 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 DIF: Remembering REF: p 113 OBJ: 8.7 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 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.” http://getbooksolutions.com 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 DIF: Remembering REF: p 113 OBJ: 8.7 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination MULTIPLE RESPONSE 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 http://getbooksolutions.com 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) DIF: Understanding REF: p 114 OBJ: 8.7 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 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 http://getbooksolutions.com 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 longterm goals, identifies outcome indicators, and lists nursing interventions for patientcentered 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 MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination 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 http://getbooksolutions.com 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 DIF: Remembering REF: p 106 OBJ: 8.3 TOP: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination Measurable goals are: (Select all that apply.) a specific b concrete http://getbooksolutions.com 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 DIF: Remembering REF: p 109 OBJ: 8.5 TOP: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care NOT: Concepts: Care Coordination