Deck 14: Planning

Question 1

In practice, for nurses to provide holistic individualised care, the care plan usually incorporates:

A) individual care plan.
B) standardised care plan.
C) both standard and individual care plan.
D) informal care plans.

Answer 1

both standard and individual care plan.

Question 2

A nurse is helping a client with planning following a surgery in which the client had a permanent colostomy placed. Why is it important to consider short-term goals for this client?

A) There may be frustration that long-term goals might seem difficult to attain.
B) The client requires health care for a short time scale.
C) To observe if the planned care for the client is meeting its goals.
D) To promote a gradual increase in personal achievement.

Answer 2

There may be frustration that long-term goals might seem difficult to attain.

Question 3

The use of standardised nursing language using a goal focus classification system is beneficial to clients because:

A) it facilitates documentation in electronic records.
B) it results in a holistic individualised plan.
C) it fosters the education of professional nurses.
D) it helps standardise collaborative care.

Answer 3

it results in a holistic individualised plan.

Question 4

A client has been seeing a nurse practitioner for counselling following a rape. A long-term goal for this client would be which of the following?

A) Client will devise a list of phone numbers of support people.
B) Client will return to level of purpose and functioning as before the rape.
C) Client will state signs and symptoms of physical trauma.
D) Client will be able to share feelings of fear with counsellor.

Question 5

A client with beginning stages of Alzheimer's disease is being admitted to an assisted living facility. The nurse is helping the client and family with the adjustment process and planning long- and short-term goals for the client as well as the family. An appropriate, realistic short-term goal for this client would be which of the following?

A) Client will be oriented to the surroundings.
B) Client will maintain a normal weight.
C) Client will be able to verbalise feelings of anger, fear and trust, when appropriate.
D) Client will not wander out of the facility.

Question 6

The client is admitted to a comprehensive rehabilitation centre for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care. Of the following, who might be involved with the ongoing planning of this client's care?

A) All nurses who work with the client.
B) Everybody involved in this client's care.
C) The client and the client's support system.
D) The admitting nurse is still responsible.

Question 7

A nurse is caring for a client in a trauma ICU in the middle of the night. The client is having difficulty maintaining blood pressure and the nurse administers a routinely used medication for this problem. This is an example of the nurse implementing which of the following?

A) A PRN order.
B) A one-time order.
C) A standing order.
D) A STAT order.

Question 8

A nurse manager is implementing computerised care plans for the units of the hospital. Which of the following guidelines should be followed when writing care plans?

A) Include all the steps for a procedure in the written plan.
B) Plans may be broad for the planned interventions.
C) Plans may not necessarily incorporate preventive and health maintenance aspects.
D) Plans must include goals and interventions for ongoing assessment.

Question 9

A nurse is just starting a job at a new hospital. As part of the orientation process, the nurse must review the hospital's policies and procedures for nursing care. Standards of care, standardised care plans, protocols, policies and procedures are developed and accepted by the nursing staff for which of the following reasons?

A) Make sure all clients have the same types of care.
B) Eliminate planning disparities among clients.
C) Promote efficient use of the nurses' time.
D) Saves them from having to think.

Question 10

A client has just given birth to a premature infant via emergency C-section. Why is it important for the nurse and the client to establish priority setting during the care planning?

A) There is usually an abundance of resources available for planned interventions.
B) It is very seldom that the client disagrees with the nurse.
C) Priorities change as the patient's responses, problems and therapies change.
D) Values concerning health may be more important to the nurse than to the patient.

Question 11

When implementing a care plan, the nurse involves a client who is ready for discharge in the planning. When does discharge planning begin?

A) When the client is ready for discharge.
B) When the client makes it known that there may be ongoing needs.
C) At first patient contact.
D) When interventions have been established and some of the goals are being achieved.

Question 12

A client has been in the hospital for several days following a CVA (cerebrovascular accident). One of the diagnoses formulated for this client is, "Risk for aspiration, related to neuromuscular dysfunction". Of the following interventions, which includes a rationale?

A) Clear secretions from oral/nasal passageways as needed.
B) Keep client in low-Fowler's position to prevent reflux.
C) Have suction equipment available at all times.
D) Provide frequent assessment for presence of obstructive material in mouth and throat.

Question 13

A nurse who is familiar with the use of standardised nursing language in Managed Care, moves to a new Australian city and begins work in a hospital. The nurse understands that this system can be compared to which of the following?

A) Implementation phase of the care plan.
B) Nursing diagnosis statement.
C) Planning portion of the care plan.
D) Goal statement of the traditional care plan.

Question 14

A nurse is working in the neonatal intensive care unit. A newly admitted, premature baby is having difficulty maintaining body temperature. The nurse implements several actions to prevent further complications. The nurse finds these actions in what type of document?

A) Standardised care plan.
B) Standards of care.
C) Policy and procedure manual.
D) Protocol.

Question 15

A client is admitted for a scheduled, elective hip replacement after having pain and limited mobility for several years. The client's plan of care would most likely be taken from which of the following?

A) Formal nursing care plan.
B) Informal nursing care plan.
C) Standardised care plan.
D) Individualised care plan.

Question 16

A nursing diagnosis of "Fluid volume deficit, related to active fluid loss, secondary to diarrhoea" has been formulated for a client. An appropriately written goal statement for this diagnosis would be which of the following?

A) Client will have moist mucous membranes.
B) Client will have an intake of at least 1000 mL within 24 hours.
C) Client will have good skin turgor.
D) Client will drink more fluids by tomorrow.

Question 17

A patient care plan that includes all nursing and collaborative goals and interventions is called a:

A) formal care plan.
B) individual care plan.
C) multidisciplinary care plan.
D) computerised care plan.

Question 18

The purpose of establishing patient goals includes all of the following except:

A) motivation for both nurse and patient.
B) provide direction for nursing interventions.
C) show a legal care plan.
D) judging effectiveness of nursing interventions.

Question 19

A client is admitted for complications following a routine diagnostic procedure of the colon. The type of care plan that will most likely be implemented for this client is which of the following?

A) Formal nursing care plan.
B) Standardised care plan.
C) Individualised care plan.
D) Informal nursing care plan.

Question 20

A nurse is seeing a home health client who requires extensive treatment for chronic airway disease. According to the care plan, the client is to receive chest physiotherapy twice daily. The client lives alone in a rural area and does not drive. When setting priorities, the home health nurse will:

A) assist the client in finding an alternative plan for the therapy.
B) tell the client that this therapy will be impossible to receive.
C) make sure that he or she is able to get to the client's home.
D) make arrangements to have the client moved to a long-term care facility.

Question 21

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

A) Impaired swallowing.
B) Upright in a chair.
C) 60 to 90 degrees during feeding times.
D) Position in chair.

Question 22

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

A) Administer medications to improve muscle tone.
B) Provide assistive devices and educate client to use grab bar and large-handled utensils.
C) Make sure lighting and space are adequate for client.
D) Provide assistance as needed with dressing and grooming.

Question 23

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

A) Client will ambulate in hallway twice daily.
B) Ambulate with client, using a gait belt, twice daily for 15 minutes.
C) Assist client with ambulation.
D) Make sure client understands the rationale for using the gait belt.

Question 24

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

A) Measuring intake and output for the client.
B) Responsibility for total nursing care.
C) Responsibility for hygiene.
D) Mobilisation and comfort.

Question 25

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

A) consider interventions based on sound judgment and knowledge of the client.
B) transfer responsibility to the delegated person.
C) ensure that the nurse evaluates care autonomously.
D) help the nurse choose activities that are individualised to the client.

Question 26

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

A) Provide ongoing assessment for skin breakdown during every shift.
B) Cushion bony prominences with soft foam while in bed.
C) Turn and reposition client every two hours.
D) Apply lotion to dry skin twice daily.

Question 27

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

A) Administering medications for pain.
B) Assisting the client with transfers to the bathroom.
C) Repositioning the client every two hours.
D) Providing ongoing physical assessment, especially of the incisional sites.

Question 28

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

A) Congruent with the client's values, beliefs and culture.
B) Within established standards of care.
C) Achievable with the resources available.
D) All of the above criteria.

Question 29

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

A) It ensures that planned nursing interventions are clearly related to the diagnosis.
B) So that nursing activities can be better managed.
C) So that the desired outcomes can be achieved by the nursing team.
D) So that the nurse can accomplish her set plan.