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

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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

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.

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

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
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination

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.

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

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 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

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 “longterm” 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:

TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination

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.

8.3




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

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 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 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

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 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

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment:
Management of Care
NOT: Concepts: Care Coordination

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.

DIF: Understanding

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

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.

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




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




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




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.

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




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




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,




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




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




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.




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.”

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

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).

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

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 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

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.