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Chapter 018

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 18: Planning Nursing Care MULTIPLE CHOICE 1. The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to prioritizing her request? 1. Low priority 2. An unmet need 3. Intermediate priority 4. A safety and security need ANS: 1 The client’s request would be
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 1: Planning Nursing Care! #T$P#E C%$CE 1.The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to prioritizing her request?1.Low priority.!n unmet need .#ntermediate priority$.! safety and security need!%&'1The client(s request would be of low priority because it is not directly related to a specificillness or prognosis. !n unmet need is not the most appropriate label for the client(s request. The client(s request is not an intermediate priority. !n intermediate priority is one that involves the non)emergent* non+life)threatening needs of the client. The client(s request is not a safety and security need, the outcome does not threaten her well)being.-#'!/0'234'5nowledgeT26'%ursing 6rocess' 6lanning7&8'%8L09: test plan designation' ;ealth 6romotion and 7aintenance.!ssuming that all of the following are realistic* a long)term goal for a client that is a tailor by trade and has been admitted for eye surgery should include'1./eturning to sewing.6reventing ocular infection .!dministering eye drops on time in the hospital $.6erforming independent hygienic care in the hospital!%&'1Long)term goals focus on prevention* rehabilitation* discharge* and health education. !n appropriate long)term goal for this client would be for rehabilitation and the client(s return to occupation* in this case sewing. 6reventing ocular infection is a short)term goal. ! short)term goal is e<pected to be achieved within a short time* usually in less than 1 week. #n 1 weeks( time* the client(s risk for infection should be greatly reduced. !dministering eye drops on time in the hospital is a short)term goal. Long)term goals are usually designed for problem resolution after discharge* especially from an acute care setting. 6erforming independent hygienic care in the hospital is a short)term goal. Long)term goals are usually made for problem resolution after discharge* especially from an acute care setting.-#'!/0'=234'5nowledgeT26'%ursing 6rocess' 6lanning7&8'%8L09: test plan designation' ;ealth 6romotion and 7aintenance 7osby items and derived items > @* = by 7osby* #nc.* an affiliate of 0lsevier #nc.  Test 3ank  .The nurse writes the following goal for a client who is hypertensive' A8lient will maintain a blood pressure within acceptable limits.B Which of the following would be themost appropriate outcome criterion?1.A8lient will request pain medication as needed.B.A8lient will e<perience no headache or dizziness.B .A8lient will identify at least two things that cause stress.B$.A8lient will have a C !7 blood pressure reading less than 1$D@.B !%&'$A8lient will have a C !7 blood pressure reading less than 1$D@B would be the most appropriate outcome criterion. #t is client)centered* singular* observable* measurable* time)limited* and realistic. A8lient will request pain medication as neededB does not allowthe nurse to be able to determine if change has taken place. #t would be more measurable to state the client will rate pain below $ on a scale of  to 1 by $ hours. A8lient will e<perience no headache or dizzinessB is not time)limited. A8lient will identify at least twothings that cause stressB is not time)limited or singular.-#'!/0'234'8omprehensionT26'%ursing 6rocess' 6lanning7&8'%8L09: test plan designation' ;ealth 6romotion and 7aintenance$.%ursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician) or prescriber)initiated?1.Teaching a client to administer his or her insulin inEection.!ssisting a new mother with learning the art of breast)feeding .%otifying the nutritionist of a client(s specific dietary preferences$.!dministering a cleansing enema in preparation for radiological testing!%&'$6reparing a client for a diagnostic test is an e<ample of a physician)initiated intervention. Teaching a client to administer his or her insulin inEection is an e<ample of a nurse)initiated intervention. !ssisting a new mother with breast)feeding is an e<ample of a nurse)initiated intervention. %otifying a nutritionist of a client(s dietary preferences is a collaborative intervention.-#'!/0'F234'8omprehensionT26'%ursing 6rocess' 6lanning7&8'%8L09: test plan designation' ;ealth 6romotion and 7aintenance=.%ursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The intervention statement A%urse will apply warm* wet soaks to the patient(s leg while awakeB lacks which of the following components?1.7ethod.Guantity 7osby items and derived items > @* = by 7osby* #nc.* an affiliate of 0lsevier #nc. 1F)  Test 3ank  .requency$.6erforming staff !%&' The intervention statement does not include how frequently the warm soaks should be applied. The method is applying warm* wet soaks to the patient(s leg while awake. The quantity is warm* wet soaks. The qualification of the person who will perform the action is the designation of Athe nurse.B-#'!/0'C 234'5nowledgeT26'%ursing 6rocess' 6lanning7&8'%8L09: test plan designation' ;ealth 6romotion and 7aintenance.#n order that they are clear and easily understood by other members of the health care team* the nurse recognizes that client goals or outcomes should be documented accordingto specific criterion. 2f the following* the outcome statement that best meets the established criteria is'1.A8lient will describe activity restrictions.B.A8lient will verbalize understanding of treatments.B .A8lient will be ambulated in hallway times each day.B$.A8lient(s respiratory rate will remain within  to $ breaths per minute by @D$.B!%&'$A8lient(s respiratory rate will remain within  to $ breaths per minute by @D$B is a correctly written outcome statement. #t is client)centered* singular* observable* measurable* time)limited* and realistic. A8lient will describe activity restrictionsB is not time)limited. A8lient will verbalize understanding of treatmentsB is not observable or time)limited. AThe client will state the purpose of the breathing treatments by $D1B would be more appropriate. A8lient will be ambulated in hallway times each dayB is notclient)centered. ! correct outcome statement would be A8lient will ambulate in the hall times a day.B-#'!/0'C234'8omprehensionT26'%ursing 6rocess' 6lanning7&8'%8L09: test plan designation' ;ealth 6romotion and 7aintenanceC.The client is receiving postural drainage from physical therapy and intermittent breathing treatments from respiratory therapy. Which type of care plan would be the ideal method to document interventions for this client?1.%ursing 5arde<.8omputerized care plan .8ritical pathway$.&tandardized care plan!%&' 7osby items and derived items > @* = by 7osby* #nc.* an affiliate of 0lsevier #nc. 1F)   Test 3ank 8ritical pathways allow staff from all disciplines to develop integrated care plans for a  proEected length of stay or number of visits for clients with a specific case type. The nursing 5arde< is a card)filing system that allows quick reference to the particular needs of the client for certain aspects of nursing care. ! computerized care plan is a standardized care plan on the computer. ! standardized care plan is a prewritten plan created for a specific nursing diagnosis or clinical problem. The nurse individualizes the care plan for the client(s needs.-#'!/0'C$234'5nowledgeT26'%ursing 6rocess' 6lanning7&8'%8L09: test plan designation' ;ealth 6romotion and 7aintenanceF.The nurse is involved in requesting a management consultation for personnel)related issues. Which of the following is true regarding the consultation process in which the nurse is involved?1.The problem area should be totally delegated to the consultant..8onsultation is often used when the e<act problem remains unclear. .The problem area is identified by any member of the health care team.$.eelings about the problem should be described to the consultant by the nurse.!%&'8onsultation is appropriate when the nurse has identified a problem that cannot be solvedusing personal knowledge* skills* and resources* or when the e<act problem remains unclear. ! consultant obEectively entering a situation can more clearly assess and identify the e<act nature of the problem. The whole problem is not turned over to the consultant. The consultant is not there to take over the problem but is there to assist the nurse in resolving it. The person requesting the consult usually identifies the problem area. The nurse should not bias the consultant with subEective and emotional conclusions about the client and problem.-#'!/0'C234'8omprehensionT26'%ursing 6rocess' 6lanning7&8'%8L09: test plan designation' ;ealth 6romotion and 7aintenance@.#n completing an assessment on an assigned client* the nurse obtains important information for planning nursing care. Which of the following client needs should take  priority?1.-ifficulty breathing.inancial problems .! nutritional deficit$.!n impending divorce!%&'1 7osby items and derived items > @* = by 7osby* #nc.* an affiliate of 0lsevier #nc. 1F)$

Chapter 011

Jul 23, 2017

Chapter 014

Jul 23, 2017
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