Chapter 16, 17, 18, 19 and 20: Nursing Assessment Potter et al.: Fundamentals of Nursing, 9th edition MULTIPLE CHOICE QUESTIONS AND ANSWERS

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Chapter 16, 17, 18, 19 and 20: Nursing Assessment Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE: QUESTIONS AND ANSWERS Chapter 16: Nursing Assessment 1. The nurse is usin... g critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a. Completes a comprehensive database b. Identifies pertinent nursing diagnoses c. Intervenes based on priorities of patient care d. Determines whether outcomes have been achieved ANS: A The assessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The nurse carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process. DIF:Apply (application)REF:210
OBJ: Discuss the relationship between critical thinking and nursing assessment. TOP:AssessmentMSC:Health Promotion and Maintenance 2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? a. Complete the questions in chronological order. b. Focus on the patient’s presenting situation. c. Make accurate interpretations of the data. d. Conduct an observational overview. ANS: B A problem-oriented approach focuses on the patient’s current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection. DIF:Apply (application)REF:210 | 213 OBJ: Describe the methods of data collection. TOP: Assessment MSC:Health Promotion and Maintenance 3. After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? a. Administer scheduled medications assuming that the NAP would have reported abnormal vital signs. b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upo c. Ask the NAP to record the patient’s vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress. ANS: C The nurse should ask the nursing assistive personnel to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action. DIF:Analyze (analysis)REF:210 OBJ: Discuss the relationship between critical thinking and nursing assessment. TOP: Implementation MSC: Health Promotion and Maintenance
 4. The nurse is gathering data on a patient. Which data will the nurse report as objective data? a. States ―doesn’t feel good‖ b. Reports a headache c. Respirations 16 d. Nauseated ANS: C Objective data are observations or measurements of a patient’s health status, like respirations. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. States ―doesn’t feel good,‖ reports a headache, and nausea are all subjective data. Subjective data include the patient’s feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition. DIF:Apply (application)REF:214
OBJ: Differentiate between subjective and objective data. TOP: Assessment MSC:Health Promotion and Maintenance 5. A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data? a. The patient can now perform the dressing changes without help. b. The patient can begin retaking all of the previous medications. c. The patient is apprehensive about discharge. d. The patient’s surgery was not successful. ANS: C Subjective data include expressions of fear of going home and being alone. These data indicate (use inference) that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed. DIF:Apply (application)REF:212-213
OBJ: Differentiate between subjective and objective data. TOP: Assessment
MSC: Psychosocial Integrity
6. Which method of data collection will the nurse use to establish a patient’s database? a. Reviewing the current literature to determine evidence-based nursing actions b. Checking orders for diagnostic and laboratory tests c. Performing a physical examination d. Ordering medications ANS: C You will learn to conduct different types of assessments: the patient-centered interview during a nursing health history, a physical examination, and the periodic assessments you make during rounding or administering care. A nursing database includes a physical examination. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. The nurse uses results from the diagnostic and laboratory tests to establish a patient database, not checking orders for tests. DIF:Understand (comprehension)REF:211 OBJ: Describe the methods of data collection. TOP: Assessment MSC:Health Promotion and Maintenance 7. A nurse is gathering information about a patient’s habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information? a. Carefully review lab results. b. Conduct the physical assessment. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview. ANS: C The nursing health history also includes a description of a patient’s habits and lifestyle patterns. Lab results and physical assessment will not reveal as much about the patient’s habits and lifestyle patterns as the nursing health history. Collecting data is part of the working phase of the interview. DIF:Analyze (analysis)REF:219 OBJ: Describe the methods of data collection. TOP: Assessment MSC:Health Promotion and Maintenance 8. While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? a. Consider cultural differences during this assessment. b. Ask the patient to make eye contact to determine her affect. c. Continue with the interview and document that the patient is depressed. d. Notify the health care provider to recommend a psychological evaluation. ANS: A To conduct an accurate and complete assessment, consider a patient’s cultural background. This nurse needs to practice culturally competent care and appreciate the cultural differences. Assuming that the patient is depressed or in need of a psychological evaluation or to force eye contact is inappropriate. DIF:Apply (application)REF:218-219 OBJ: Explain ways to make an assessment patient centered. TOP: Assessment MSC: Psychosocial Integrity 9. A nurse has already set the agenda during a patient-centered interview. What will the nurse do next? a. Begin with introductions. b. Ask about the chief concerns or problems. c. Explain that the interview will be over in a few minutes. d. Tell the patient ―I will be back to administer medications in 1 hour.‖ ANS: B After setting the agenda, the nurse should conduct the actual interview and proceed with data collection, such as asking about the patient’s current chief concerns or problems. Introductions occur before setting the agenda. Begin an interview by introducing yourself and your position and explaining the purpose of the interview. Your aim is to set an agenda for how you will gather information about a patient’s current chief concerns or problems. The termination phase includes telling the patient when the interview is nearing an end. Telling the patient that medications will be given later when the nurse returns would typically take place during the termination phase of the interview. DIF:Understand (comprehension)REF:216 OBJ: Discuss how to conduct a patient-centered interview. TOP: Assessment MSC:Health Promotion and Maintenance 10. The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask? a. ―Is there anything that you are stressed about right now that I should know?‖ 
 b. ―What reasons do you think are contributing to your fatigue?‖ c. ―What are your normal work hours?‖ 
 d. ―Are you sleeping 8 hours a night?‖ 
 ANS: B The question asking the patient what factors might be contributing to the fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking about normal work hours will elicit a matter-of-fact response and does not prompt the patient to elaborate on the daytime fatigue or ask about the contributing reasons. DIF:Apply (application)REF:216-217
OBJ: Discuss how to conduct a patient-centered interview. TOP: Assessment
MSC:Health Promotion and Maintenance
11. A nurse is conducting a nursing health history. Which component will the nurse address? a. Nurse’s concerns b. Patient expectations c. Current treatment orders d. Nurse’s goals for the patient ANS: B Some components of a nursing health history include chief concern, patient expectations, spiritual health, and review of systems. Current treatment orders are located under the Orders section in the patient’s chart and are not a part of the nursing health history. Patient concerns, not nurse’s concerns, are included in the database. Goals that are mutually established, not nurse’s goals, are part of the nursing care plan. DIF:Understand (comprehension)REF:219
OBJ: Describe the components of a nursing history. TOP: Assessment MSC:Health Promotion and Maintenance 12. While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? a. Tell the patient to just focus on the leg and cast right now. b. Document the sleep patterns and information in the patient’s chart. c. Explain that a more thorough assessment will be needed next shift. d. Ask the patient about usual sleep patterns and the onset of having difficulty resting. ANS: D The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient’s report of a problem or postpone it till the next shift. DIF:Analyze (analysis)REF:210 | 212 | 219 OBJ:Conduct a nursing assessment.TOP:Assessment MSC:Health Promotion and Maintenance 13. The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? a. Gordon’s Functional Health Patterns 
 b. Activity-exercise pattern assessment 
 c. General to specific assessment 
 d. Problem-oriented assessment ANS: D The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand (dressing and drainage from surgery) and performs a problem-oriented assessment. Utilizing Gordon’s Functional Health Patterns is an example of a structured database-type assessment technique that includes 11 patterns to assess. The nurse in this question is performing a specific problemoriented assessment approach, not a general approach. The nurse is not performing an activity-exercise pattern assessment in this question. DIF:Apply (application)REF:213
OBJ: Describe the methods of data collection. TOP: Assessment MSC:Health Promotion and Maintenance 14. Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? a. ―Data interpretation occurs before data validation.‖ 
 b. ―Validation involves looking for patterns in professional standards.‖ 
 c. ―Validation involves comparing data with other sources for accuracy.‖ 
 d. ―Data interpretation involves discovering patterns in professional standards.‖ 
 ANS: C Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards. DIF:Understand (comprehension)REF:220 OBJ: Explain the relationship between data interpretation and validation. TOP:AssessmentMSC:Health Promotion and Maintenance 15. Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing ch a. and notices old and new drainage. 
The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and th 
 b. wants something done. 
 c. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg c 
 d. The nurse elevates a leg cast when the patient reports decreased mobility. 
 ANS: A The only scenario that validates a patient’s report with a nurse’s observation is changing the wound dressing. The nurse validates what the patient says by observing the dressing. The rest of the examples have the nurse acting only from a patient and/or family reports, not the nurse’s assessment. DIF:Analyze (analysis)REF:220 OBJ: Explain the relationship between data interpretation and validation. TOP:AssessmentMSC:Health Promotion and Maintenance 16. While completing an admission database, the nurse is interviewing a patient who states ―I am allergic to latex.‖ Which action will the nurse take first? a. Immediately place the patient in isolation. 
 b. Ask the patient to describe the type of reaction. 
 c. Proceed to the termination phase of the interview. 
 d. Document the latex allergy on the medication administration record. 
 ANS: B The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered. DIF:Apply (application)REF:219 OBJ:Conduct a nursing assessment.TOP:Assessment MSC:Health Promotion and Maintenance 17. A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations? a. Proceed to the next patient’s room to make rounds. 
 b. Determine the patient does not want any pain medicine. 
 c. Ask the patient about the facial grimacing with movement. d. Administer the pain medication ordered for moderate to severe pain. ANS: C First, the nurse needs to clarify/verify what was observed with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse cannot assume the patient does not want pain medicine just because he reports a 2 out of 10 on the pain scale. The nurse should not administer medication for moderate to severe pain if it is not necessary. DIF:Analyze (analysis)REF:212 | 220 OBJ:Conduct a nursing assessment.TOP:Assessment MSC:Health Promotion and Maintenance 18. The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview? a. The patient’s room with the door closed 
 b. The waiting area with the television turned off 
 c. The patient’s room before administration of pain medication 
 d. The waiting room while the occupational therapist is working on leg exercises 
 ANS: A Distractions should be eliminated as much as possible when interviewing a patient with a hearing deficit. The best place to conduct this interview is in the patient’s room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone’s ability to concentrate, so before pain medication is administered is not advisable. It is best for the patient to be as comfortable as possible when conducting an interview. Assessing a patient while another member of the health care team is working would be distracting and is not the best time for an interview to take place. DIF:Analyze (analysis)REF:215-216 OBJ: Describe how courtesy, comfort, connection, and confirmation establish a foundation for patient assessment. TOP: Assessment MSC: Health Promotion and Maintenance 19. A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse? a. The nurse makes eye contact with the patient. 
 b. The nurse speaks only to the patient’s daughter. 
 c. The nurse leans forward while talking with the patient. 
 d. The nurse nods periodically while the patient is speaking. 
 ANS: B Gathering data from family members is acceptable, but when a patient is able to interact, nurses need to include information from the older adult to complete the assessment. Therefore, the charge nurse must correct this misconception. When assessing an older adult, nurses need to listen carefully and allow the patient to speak. Positive nonverbal communication, such as making eye contact, nodding, and leaning forward, shows interest in the patient. Thus, the charge nurse does not need to intervene or follow up. DIF:Apply (application)REF:214-215
OBJ: Describe how developing relationships with patients fosters the assessment process. TOP:EvaluationMSC:Management of Care MULTIPLE RESPONSE 1. A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.) a. Patient’s temperature b. Patient’s wound appearance 
 c. Patient describing excitement about discharge 
 d. Patient pacing the floor while awaiting test results 
 e. Patient’s expression of fear regarding upcoming surgery 
 ANS: C, E Subjective data include patient’s feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a patient’s health status. In this question, the appearance of the wound and the patient’s temperature are objective data. Pacing is an observable patient behavior and is also considered objective data. DIF:Apply (application)REF:213-214
OBJ: Differentiate between subjective and objective data. TOP: Assessment MSC:Health Promotion and Maintenance MATCHING A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using. a. Where is the pain located? 
 b. What causes the pain? 
 c. Does it come and go? 
 d. What does the pain feel like? 
 e. What is the rating on a scale of 0 to 10? 
 1. Provokes 2. Quality 3. Radiate 4. Severity 5.Time 1.ANS:BDIF:Apply (application)REF:219
OBJ: Describe the methods of data collection. TOP: Assessment MSC: Basic Care and Comfort
2.ANS DIF:Apply (application)REF:219
OBJ: Describe the methods of data collection. TOP: Assessment MSC: Basic Care and Comfort
3.ANS:ADIF:Apply (application)REF:219
OBJ: Describe the methods of data collection. TOP: Assessment MSC: Basic Care and Comfort
4.ANS:EDIF:Apply (application)REF:219
OBJ: Describe the methods of data collection. TOP: Assessment MSC: Basic Care and Comfort
5.ANS:CDIF:Apply (application)REF:219
OBJ: Describe the methods of data collection. TOP: Assessment MSC: Basic Care and Comfort Chapter 17: Nursing Diagnosis Chapter 17: Nursing Diagnosis
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions? a. To form a language that can be encoded only by nurses 
 b. To distinguish the nurse’s role from the physician’s role 
 c. To develop clinical judgment based on other’s intuition 
 d. To help nurses focus on the scope of medical practice 
 ANS: B The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish the nurse’s role from that of the physician/health care provider and help nurses focus on the scope of nursing practice (not medical) while fostering the development of nursing knowledge. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patient’s needs. A diagnosis is a clinical judgment based on information. DIF:Understand (comprehension)REF:225 | 227 OBJ: Discuss how a nursing diagnosis guides nursing practice. TOP: Diagnosis MSC:Management of Care 2. Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved? a. b. c. d. ANS: B Sore throat Acute pain Sleep apnea Heart failure Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart failure are medical diagnoses, and sore throat is subjective data. DIF:Understand (comprehension)REF:227 | 233
OBJ: Discuss how a nursing diagnosis guides nursing practice. TOP: Diagnosis MSC:Management of Care 3. A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? ANS: D The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process of pneumonia that the nurse can treat. The related to factor should be the cause of the problem (nursing diagnosis) that a nurse can address. The related to factors of dehydration and pneumonia are all medical diagnoses that the nurse cannot change. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat. DIF:Apply (application)REF:230 | 232 | 236
OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process. TOP iagnosisMSC:Management of Care 4. The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic
statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise? a. Etiology Ineffective breathing pattern related to pneumonia Risk for infection related to chest x-ray procedure Risk for deficient fluid volume related to dehydration Impaired gas exchange related to alveolar-capillary membrane changes b. Nursing diagnosis 
 c. Collaborative problem 
 d. Defining characteristic 
 ANS: A The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s health status; there is no collaborative problem listed. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility. DIF:Apply (application)REF:233 | 235 | 236 OBJ: Differentiate among a nursing diagnosis, medical diagnosis, and collaborative problem. TOP iagnosisMSC:Management of Care 5. A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing? a. Assigning clinical cues 
 b. Defining characteristics 
 c. Diagnostic reasoning 
 d. Diagnostic labeling 
 ANS: C Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Defining characteristics are the subjective and objective clinical cues, which a nurse gathers intentionally and unintentionally. The nurse organizes all of the patient’s data into meaningful and usable data clusters, which lead to a diagnostic conclusion. Diagnostic labeling is simply the name of the diagnosis. DIF:Understand (comprehension)REF:230
OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process. TOP iagnosisMSC:Management of Care 6. A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care? ANS: C Posttrauma syndrome Constipation
Acute pain
Anxiety Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is ―Reports only moderate discomfort,‖ which would support Acute pain. No supportive evidence is provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other problems, but supportive data are presently lacking in the provided information. DIF:Apply (application)REF:230 | 233
OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process. TOP iagnosisMSC:Management of Care 7. The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a. Diagnosis 
 b. Planning 
 c. Implementation 
 d. Evaluation 
 ANS: A After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions; this is the diagnosis phase. The evaluation phase involves determining whether the goals were met and interventions were effective. DIF:Apply (application)REF:226 | 230
OBJ: Describe the steps of the nursing diagnostic process. TOP: Diagnosis MSC:Management of Care 8. A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write? a. Risk 
 b. Problem focused 
 c. Health promotion 
 d. Collaborative problem 
 ANS: C A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and actualize human health potential. A problem-focused nursing diagnosis describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group or community for developing an undesirable human response to health conditions/life processes. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s health status. DIF:Apply (application)REF:227 | 230 OBJ escribe the differences among health promotion, problem focused, and risk nursing diagnoses.TOP iagnosisMSC:Management of Care 9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient’s blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a. Assessment 
 b. Diagnosis 
 c. Implementation 
 d. Evaluation 
 ANS: A The diagnostic process should flow from the assessment. In this case, the nurse should have assessed the patient’s blood pressure before giving the medication. The nurse could have prevented the patient’s untoward reaction if the low blood pressure was assessed first. Diagnosis follows assessment. Administering the medication occurs in implementation, but this is not the first error. There are no errors in evaluation. DIF:Apply (application)REF:226 | 230 | 233
OBJ: Discuss the relationship of critical thinking to the nursing diagnostic process. TOP iagnosisMSC:Management of Care 10. A nurse adds the following diagnosis to a patient’s care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic? a. Decreased gastrointestinal motility 
 b. Pain medication 
 c. Abdominal distention 
 d. Constipation 
 ANS: C Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation (problem or NANDA-1 diagnosis) is the identified problem derived from the defining characteristics. DIF:Apply (application)REF:227 | 230 | 231 | 233 OBJ:Explain how defining characteristics and the etiological factor individualize a nursing diagnosis.TOP iagnosisMSC:Management of Care 11. The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance? a. Decreased oral intake and decreased oxygen saturation when ambulating 
b. Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed 
 c. Reports of shortness of breath when getting out of bed and a productive cough 
 d. Productive cough and decreased oral intake 
 ANS: B There are defining characteristics (observable assessment cues such as patient behavior, physical signs) that support each problem-focused diagnostic judgment. The signs and symptoms, or defining characteristics, for the diagnosisActivity intolerance include decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed. The key to supporting the diagnosis of Activity intolerance is that only these two characteristics involve how the patient tolerates activity. Decreased oral intake and productive cough do not define activity intolerance. DIF:Analyze (analysis)REF:230 | 233 OBJ:Explain how defining characteristics and the etiological factor individualize a nursing diagnosis.TOP iagnosisMSC:Management of Care 12. A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain? a. Discomfort while changing position 
 b. Reports pain as a 7 on a 0 to 10 scale 
 c. Disruption of tissue integrity 
 d. Dull headache 
 ANS: C Disruption of tissue integrity is a possible cause or etiology of pain. A report of pain, headache, and discomfort are examples of things a patient might say (subjective data or defining characteristics) that may lead a nurse to selectAcute pain as a nursing diagnosis. DIF:Apply (application)REF:232-233 OBJ:Explain how defining characteristics and the etiological factor individualize a nursing diagnosis.TOP iagnosisMSC:Management of Care 13. A new nurse writes the following nursing diagnoses on a patient’s care plan. Which nursing diagnosis will cause the nurse manager to intervene? a. b. c. d. ANS: B Wandering Hemorrhage Urinary retention Impaired swallowing Hemorrhage is a collaborative problem, not a nursing diagnosis; the nurse manager will need to correct this misunderstanding with the new nurse. Nurses manage collaborative problems such as hemorrhage, infection, and paralysis using medical, nursing, and allied health (e.g., physical therapy) interventions. Wandering, urinary retention, and impaired swallowing are all examples of nursing diagnoses. DIF:Analyze (analysis)REF:225 | 231 | 232 OBJ: Differentiate among a nursing diagnosis, medical diagnosis, and collaborative problem. TOP iagnosisMSC:Management of Care 14. A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient’s care plan? a. Infection b. c. d. ANS: C Risk for infection
Impaired skin integrity Staphylococcal leg infection Impaired skin integrity is the only nursing diagnosis listed that will correlate to the patient information. While risk for infection is a nursing diagnosis, the patient is not at risk; the patient has an actual infection. Infection can be a medical diagnosis as well as a collaborative problem. Staphylococcal leg infection is a medical diagnosis. DIF:Apply (application)REF:225 OBJ: Differentiate among a nursing diagnosis, medical diagnosis, and collaborative problem. TOP iagnosisMSC:Management of Care 15. A nurse adds a nursing diagnosis to a patient’s care plan. Which information did the nurse document? a. Decreased cardiac output related to altered myocardial contractility. 
 b. Patient needs a low-fat diet related to inadequate heart perfusion. 
 c. Offer a low-fat diet because of heart problems. 
 d. Acute heart pain related to discomfort. 
 ANS: A Decreased cardiac output related to altered myocardial contractility is a correctly written nursing diagnosis. Patient needs a low-fat diet related to inadequate heart perfusion is a goal phrased statement, not a nursing diagnosis. Offer a low-fat diet is an intervention, not a diagnosis. Acute pain related to discomfort is a circular diagnosis and gives no direction to nursing care. DIF:Apply (application)REF:230 | 233 | 234-236 OBJ: Describe sources of diagnostic errors. TOP: Diagnosis MSC:Management of Care 16. A charge nurse is evaluating a new nurse’s plan of care. Which finding will cause the charge nurse to follow up? a. b. Completing an interview and physical examination before adding a nursing diagnosis 
 c. Developing nursing diagnoses before completing the database 
 d. Including cultural and religious preferences in the database 
 ANS: C Developing nursing diagnoses before completion of the database needs to be corrected by the charge nurse. Always identify a nursing diagnosis from the data, not the reverse. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview and physical examination before adding a nursing diagnosis is appropriate. The patient’s cultural background and developmental stage are important to include in a patient database. DIF:Analyze (analysis)REF:230 | 234-236
OBJ: Describe sources of diagnostic errors. TOP: Diagnosis MSC:Management of Care 17. A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient? Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibioti a. b. c. d. ANS: C Adult failure to thrive Hypothermia Deficient fluid volume Nausea The signs the patient is exhibiting are consistent with deficient fluid volume (dehydration). Even without knowing the clinical manifestations of dehydration, the question can be answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are not appropriate diagnoses because data are insufficient to support these diagnoses. DIF:Analyze (analysis)REF:230 | 233 OBJ: Identify nursing diagnoses from a nursing assessment. TOP: Diagnosis MSC:Management of Care 18. Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a. ―What types of foods do you think caused your upset stomach?‖ 
b. ―How many bowel movements a day have you had?‖ 
 c. ―Are you able to get to the bathroom in time?‖ 
 d. ―What medications are you currently taking?‖ 
 ANS: B The nurse needs to first ensure that the symptoms support the diagnosis. By definition, diarrhea means that a patient is having frequent stools; therefore, asking about the number of bowel movements is most appropriate. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate. Asking the patient if he can make it to the bathroom will help to establish a diagnosis of incontinence, not diarrhea. The question is asking for the most appropriate statement to establish the diagnosis of Diarrhea. DIF:Analyze (analysis)REF:230 OBJ: Identify nursing diagnoses from a nursing assessment. TOP: Diagnosis MSC:Management of Care 19. A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention? a. ―Do you feel like you need to go to the bathroom?‖ 
 b. ―Are you able to walk to the bathroom by yourself?‖ 
 c. ―When was the last time you took your medicine?‖ 
 d. ―Do you have a safety rail in your bathroom at home?‖ 
 ANS: A The nurse must establish that the patient feels the urge and is unable to void. The question ―Do you feel like you need to go to the bathroom?‖ is the most appropriate to ask. This question can be answered without knowledge of the diagnosis of Urinary retention. Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues, not to retention of urine. Taking certain medications may lead to urinary retention, but that information would establish the etiology. The question is asking for the nurse to first establish the correct diagnosis. DIF:Analyze (analysis)REF:230 | 235
OBJ: Identify nursing diagnoses from a nursing assessment. TOP: Diagnosis MSC:Management of Care 20. A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma 2. Writes a diagnostic label of impaired gas exchange
3. Organizes data into meaningful clusters
4. Interprets information from patient 5. Writes an etiology a. 1, 3, 4, 2, 5 
 b. 1, 3, 4, 5, 2 
 c. 1, 4, 3, 5, 2 
 d. 1, 4, 3, 2, 5 
 ANS: A The diagnostic process flows from the assessment process (observing and gathering data) and includes decision-making steps. These steps include data clustering, identifying patient health problems, and formulating the diagnosis (diagnosis is written as problem or NANDA-I approved diagnosis then etiology or cause). DIF:Apply (application)REF:230-231
OBJ: Describe the steps of the nursing diagnostic process. TOP: Diagnosis MSC:Management of Care MULTIPLE RESPONSE 1. A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.) a. b. Anxiety related to barium enema Impaired gas exchange related to asthma c. d. e. Impaired physical mobility related to incisional pain Nausea related to adverse effect of cancer medication Risk for falls related to nursing assistive personnel leaving bedrail down ANS: C, D Impaired physical mobility and Nausea are the only correctly written nursing diagnoses. All the rest are incorrectly written. Anxiety lists a diagnostic test as the etiology. Impaired gas exchange lists a medical diagnosis as the etiology. Risk for falls has a legally inadvisable statement for an etiology. DIF:Apply (application)REF:233-236
OBJ: Describe sources of diagnostic errors. TOP: Diagnosis MSC:Management of Care Chapter 18: Planning Nursing Care Chapter 18: Planning Nursing Care
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process? a. Assessment 
 b. Diagnosis 
 c. Planning 
 d. Implementation 
 ANS: C After identifying a patient’s nursing diagnoses and collaborative problems, a nurse prioritizes the diagnoses, sets patient-centered goals and expected outcomes, and chooses nursing interventions appropriate for each diagnosis. This is the third step of the nursing process, planning. The assessment phase of the nursing process involves gathering data. The implementation phase involves carrying out appropriate nursing interventions. During the evaluation phase, the nurse assesses the achievement of goals and effectiveness of interventions. DIF:Understand (comprehension)REF:240
OBJ: Explain the relationship of planning to assessment and nursing diagnosis. TOP lanningMSC:Management of Care 2. A patient’s plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall.
Which initial action will the nurse take next to revise the plan of care? a. Consult physical therapy. 
 b. Establish a new plan of care. 
 c. Set new priorities for the patient. 
 d. Assess the patient. 
 ANS: D Nurses revise a plan when a patient’s status changes; assessment is the first step. Know also that a plan of care is dynamic and changes as the patient’s needs change. Asking physical therapy to assist the patient is premature before assessing the patient and awaiting the health care provider’s orders. The nurse may not need to disregard all previous diagnoses. Some diagnoses may still apply, but the patient needs to be assessed first. Setting new priorities is not recommended before assessment and establishing diagnoses. DIF:Apply (application)REF:241 | 248
OBJ: Discuss criteria used in priority setting. TOP: Planning MSC:Management of Care
3. Which information indicates a nurse has a good understanding of a goal? a. It is a statement describing the patient’s accomplishments without a time restriction. 
 b. It is a realistic statement predicting any negative responses to treatments. 
 c. It is a broad statement describing a desired change in a patient’s behavior. 
 d. It is a measurable change in a patient’s physical state. 
 ANS: C A goal is a broad statement that describes a desired change in a patient’s condition or behavior. A goal is mutually set with the patient. An expected outcome is the measurable changes (patient behavior, physical state, or perception) that must be achieved to reach a goal. Expected outcomes are time limited, measurable ways of determining if a goal is met. DIF:Understand (comprehension)REF:242 | 243 OBJ iscuss the difference between a goal and an expected outcome. TOP lanningMSC:Management of Care 4. A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient? a. Patient will increase activity level this shift. 
 b. Patient will turn side to back to side with assistance every 2 hours. 
 c. Patient will use the walker correctly to ambulate to the bathroom as needed. 
 d. Patient will use a sliding board correctly to transfer to the bedside commode as needed. 
 ANS: A A goal is a broad statement of desired change; the patient will increase activity level is a broad statement. Turning is the expected outcome. When determining goals, the nurse needs to ensure that the goal is individualized and realistic for the patient. Since the patient is on bed rest, using a walker and bedside commode is contraindicated. DIF:Apply (application)REF:242-243 | 245 OBJ iscuss the difference between a goal and an expected outcome. TOP lanningMSC:Management of Care 5. The following statements are on a patient’s nursing care plan. Which statement will the nurse use as an outcome for a goal of care? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. 
 b. The patient will demonstrate increased tolerance to activity over the next month. 
 c. The patient will understand needed dietary changes by discharge. 
 d. The patient will demonstrate increased mobility in 2 days. 
 ANS: A An expected outcome is a specific and measurable change that is expected as a result of nursing care. Verbalizing decreased pain on a 0 to 10 scale is an outcome. The other three options in this question are goals. Demonstrating increased mobility in 2 days and understanding necessary dietary changes by discharge are short-term goals because they are expected to occur in less than a week. Demonstrating increased tolerance to activity over a month-long period is a long-term goal because it is expected to occur over a longer period of time. DIF:Apply (application)REF:243-245 OBJ: Correctly write an outcome for a goal of care. TOP: Planning MSC:Management of Care 6. A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse? a. The patient will ambulate in hallways. b. The nurse will monitor the patient’s heart rhythm continuously this shift. 
 c. The patient will feed self at all mealtimes today without reports of shortness of breath. 
 d. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort. 
 ANS: C An expected outcome should be patient centered; should address one patient response; should be specific, measurable, attainable, realistic, and timed (SMART approach). The statement ―The patient will feed self at all mealtimes today without reports of shortness of breath‖ includes all SMART criteria for goal writing. ―The patient will ambulate in hallways‖ is missing a time limit. Administering pain medication and monitoring the patient’s heart rhythm are nursing interventions; they do not reflect patient behaviors or actions. DIF:Apply (application)REF:245 OBJ: Explain the SMART approach to writing goal and outcome statements. TOP lanningMSC:Management of Care 7. A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient? b. c. d. ANS: D Risk for impaired skin integrity Risk for infection
Spiritual distress
Reflex urinary incontinence Reflex urinary incontinence is highest priority. If a patient’s incontinence is not addressed, then the patient is at higher risk of impaired skin integrity and infection. Remember that the Risk for diagnoses are potential problems. They may be prioritized higher in some cases but not in this situation. Spiritual distress is an actual diagnosis, but the adverse effects that could result from not assisting the patient with urinary elimination take priority in this case. DIF:Analyze (analysis)REF:241-242
OBJ: Develop a plan of care from a nursing assessment. TOP: Planning MSC:Management of Care 8. The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse? a. ―Choose all the interventions and perform them in order of time needed for each one.‖ 
 b. ―Make sure you identify the scientific rationale for each intervention first.‖ 
 c. ―Decide on goals and outcomes you have chosen for the patients.‖ 
 d. ―Begin with the highest priority diagnoses, then select appropriate interventions.‖ 
 ANS: D Work from your plan of care and use patients’ priorities to organize the order for delivering interventions and organizing documentation of care. When developing a plan of care, the nurse needs to rank the nursing diagnoses in order of priority, then select appropriate interventions. Choosing all the interventions should take place after ranking of the diagnoses, and interventions should be prioritized by patient needs, not just by time. The chosen interventions should be evidence based with scientific rationales, but the diagnoses need to be prioritized first to prioritize interventions. Goals for a patient should be mutually set, not just chosen by the nurse. DIF:Apply (application)REF:241-242
OBJ: Develop a plan of care from a nursing assessment. TOP: Planning MSC:Management of Care 9. A patient’s son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? a. Individualize the care plan only according to the patient’s needs. 
 b. Request that the son leave at bedtime, so the patient can rest. 
 c. Suggest that a female member of the family stay with the patient. 
 d. Involve the son in the plan of care as much as possible. 
 ANS: D The family is often a resource to help the patient meet health care goals. Family should be included in the plan of care as much as possible. Meeting some of the family’s needs as well as the patient’s needs will possibly improve the patient’s level of wellness. The son should not be asked to leave if at all possible. In some situations, it may be best that family members not remain in the room, but no evidence in the question stem suggests that this is the case in this situation. The suggestion of asking a female member to stay is not a justified action without a legitimate reason. No reason is given in this question stem for such a suggestion. DIF:Apply (application)REF:248-249
OBJ: Develop a plan of care from a nursing assessment. TOP: Planning MSC:Management of Care 10. A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care? a. Patient will have one soft, formed bowel movement by end of shift. 
 b. Patient will walk unassisted to bathroom by the end of shift. 
 c. Patient will be offered laxatives or stool softeners this shift. 
 d. Patient will not take any pain medications this shift. 
 ANS: A The identified problem, or nursing diagnosis, is constipation. Therefore, the outcome should be that the constipation is relieved. To measure constipation relief, the nurse will be observing for the patient to have a bowel movement. During planning, you select goals and expected outcomes for each nursing diagnosis or problem to provide clear direction for the type of interventions needed to care for your patient and to then evaluate the effectiveness of these interventions. Not taking pain medications may or may not relieve the constipation. Although not taking pain medicines might be an intervention, the nurse doesn’t want the patient to be in pain to relieve constipation. Other measures, such as administering laxatives or stool softeners, might be appropriate interventions but they are not outcomes. The patient walking unassisted to the bathroom addresses mobility, not constipation. The patient may need to walk to the bathroom to have a bowel movement, but the appropriate outcome for constipation is that the constipation is relieved as evidenced by a bowel movement— something that the nurse can observe. DIF:Apply (application)REF:242 | 245 OBJ: Develop a plan of care from a nursing assessment. TOP: Planning MSC:Management of Care 11. The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform? a. Dependent 
 b. Independent 
 c. Interdependent 
 d. Physician-initiated 
 ANS: C Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals. Health care provider-initiated (HCP) interventions are dependent nursing interventions, or actions that require an order from the HCP. Nurse-initiated interventions are the independent nursing interventions, or actions that a nurse initiates without supervision or direction from others. DIF:Understand (comprehension)REF:246 OBJ: Discuss the differences among independent, dependent, and collaborative nursing interventions. TOP: Implementation MSC: Management of Care 12. A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing? a. Collaborative 
 b. Independent 
 c. Interdependent 
 d. Dependent 
 ANS: D The nurse does not have prescriptive authority to order pain medications, unless the nurse is an advanced practice nurse. The intervention is therefore dependent. Administering a medication, implementing an invasive procedure (e.g., inserting a Foley catheter, starting an intravenous [IV] infusion), and preparing a patient for diagnostic tests are examples of health care provider-initiated interventions. A collaborative, or an interdependent, intervention involves therapies that require combined knowledge, skill, and expertise from multiple health care professionals. Nurse-initiated interventions are the independent nursing interventions, or actions that a nurse initiates without supervision or direction from others. DIF:Apply (application)REF:246 OBJ: Discuss the differences among independent, dependent, and collaborative nursing interventions. TOP: Implementation MSC: Management of Care 13. Which action indicates the nurse is using a PICOT question to improve care for a patient? a. Practices nursing based on the evidence presented in court b. Implements interventions based on scientific research 
 c. Uses standardized care plans for all patients. 
 d. Plans care based on tradition 
 ANS: B The best answer is implementing interventions based on scientific research. Using results of a literature search to a PICOT question can help a nurse decide which interventions to use. Practicing based on evidence presented in court is incorrect. Practice is based on current research. Using standardized care plans may be one example of evidence-based practice, but it is not used on all patients. The nurse must be careful in using standardized care plans to ensure that each patient’s plan of care is still individualized. Planning care based on tradition is incorrect because nursing care should be based on current research. DIF:Understand (comprehension)REF:240 | 244 | 246 OBJ: Describe how use of a PICOT question can influence a patient’s plan of care. TOP lanningMSC:Management of Care 14. A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statementRisk for loneliness related to impaired verbal communication? a. Provide the patient with a writing board each shift. 
 b. Obtain an interpreter for the patient as soon as possible. 
 c. Assist the patient in performing swallowing exercises each shift. 
 d. Ask the family to provide a sitter to remain with the patient at all times. 
 ANS: A Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. If the etiology is impaired verbal communication, then the nurse should choose an intervention that will address the problem. Providing the patient with a writing board will allow the patient to communicate by writing because the patient is unable to communicate verbally at this time. Obtaining an interpreter might be an appropriate intervention if the patient spoke a foreign language. Assisting with swallowing exercises will help the patient with swallowing, which is a different etiology than impaired verbal communication. Asking the family to provide a sitter at all times is many times unrealistic and does not relate to the impaired verbal communication; the goal would relate to the loneliness. DIF:Analyze (analysis)REF:247 OBJ: Discuss the process of selecting nursing interventions during planning. TOP lanningMSC:Management of Care 15. A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statementImpaired skin integrity related to shearing forces? a. Administer pain medication every 4 hours as needed. 
 b. Turn the patient every 2 hours, even hours. 
c. Monitor vital signs, especially rhythm. 
 d. Keep the bed side rails up at all times. 
 ANS: B The most appropriate intervention for the diagnosis of Impaired skin integrity is to turn the patient. Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. The other options do not directly address the shearing forces. The patient may need pain medication, but Acute pain would be another nursing diagnosis. Monitoring vital signs does not have when or how often these should be done. Keeping the side rails up addresses safety, not skin integrity. DIF:Apply (application)REF:247
OBJ: Discuss the process of selecting nursing interventions during planning. TOP lanningMSC:Management of Care 16. A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention ismost appropriate for the nursing diagnostic statement Risk for falls? a. Keep all side rails down at all times. 
 b. Encourage patient to remain in bed most of the shift. 
 c. Place patient in room away from the nurses’ station if possible. 
 d. Assist patient into and out of bed every 4 hours or as tolerated. 
 ANS: D Risk for falls is a risk (potential) nursing diagnosis; therefore, the nurse needs to implement actions that will prevent a fall. Assisting the patient into and out of bed is the most appropriate intervention to prevent the patient from falling. Encouraging activity builds muscle strength, and helping the patient with transfers ensures patient safety. Encouraging the patient to stay in bed will not promote muscle strength. Decreased muscle strength is the risk factor placing the patient in jeopardy of falling. The side rails should be up, not down, according to agency policy. This will remind the patient to ask for help to get up and will keep the patient from rolling out of bed. The patient should be placed near the nurses’ station, so a staff member can quickly get to the room and assist the patient if necessary. DIF:Apply (application)REF:246-247
OBJ: Discuss the process of selecting nursing interventions during planning.
TOP lanningMSC:Management of Care
17. Which action will the nurse take after the plan of care for a patient is developed? a. Place the original copy in the chart, so it cannot be tampered with or revised. 
 b. Communicate the plan to all health care professionals involved in the patient’s care. 
 c. File the plan of care in the administration office for legal examination. 
d. Send the plan of care to quality assurance for review. ANS: B Setting realistic goals and outcomes often means you must communicate these goals and outcomes to caregivers in other settings who will assume responsibility for patient care. The plan of care communicates nursing care priorities to nurses and other health care professionals. Know also that a plan of care is dynamic and changes as the patient’s needs change. All health care professionals involved in the patient’s care need to be informed of the plan of care. The plan of care is not sent to the administrative office or quality assurance office. DIF:Understand (comprehension)REF:245 OBJ: Describe the role that communication plays in planning patient-centered care. TOP:ImplementationMSC:Management of Care 18. A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take? 1. Identify the problem.
2. Discuss the findings and recommendation.
3. Provide the consultant with relevant information about the problem.
4. Contact the right professional, with the appropriate knowledge and expertise.
5. Avoid bias by not providing a lot of information based on opinion to the consultant. a. 1, 4, 3, 5, 2 
 b. 4, 1, 3, 2, 5 
 c. 1, 4, 5, 3, 2 
 d. 4, 3, 1, 5, 2 
 ANS: A The first step in making a consultation is to assess the situation and identify the general problem area. Second, direct the consultation to the right professional such as another nurse or social worker. Third, provide a consultant with relevant information about the problem area and seek a solution. Fourth, do not prejudice or influence consultants. Fifth, be available to discuss a consultant’s findings and recommendations. DIF:Apply (application)REF:253 OBJ escribe the consultation process.TOP:Implementation MSC:Management of Care 19. A hospital’s wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient’s dressing changes. Which action should the nurses take next? a. Include dressing change instructions and frequency in the care plan. 
 b. Assume that the wound nurse will perform all dressing changes. 
 c. Request that the health care provider look at the wound. 
 d. Encourage the patient to perform the dressing changes. 
 ANS: A Incorporate the consultant’s recommendations into the care plan. The wound nurse clearly recommends that nurses on the unit, not the patient, should continue dressing changes. The nurses should not make a wrong assumption that the wound nurse is doing all the dressing changes. The recommendation states for the nurses to do the dressing changes. If the nurses feel strongly about obtaining another opinion, then the health care provider should be contacted. No evidence in the question suggests that the patient needs a second opinion. DIF:Apply (application)REF:253
OBJ: Describe the consultation process. TOP: Planning MSC: Management of Care MULTIPLE RESPONSE 1. A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.) a. Rank all the patient’s nursing diagnoses in order of priority. 
 b. Do not change priorities once they’ve been established. 
 c. Set priorities based solely on physiological factors. 
 d. Consider time as an influencing factor. 
 e. Utilize critical thinking. 
 ANS: A, D, E By ranking a patient’s nursing diagnoses in order of importance and always monitoring changing signs and symptoms (defining characteristics) of patient problems, you attend to each patient’s most important needs and better organize ongoing care activities. Prioritizing the problems, or nursing diagnoses, will help the nurse decide which problem to address first. Symptom pattern recognition from your assessment database and certain knowledge triggers help you understand which diagnoses require intervention and the associated time frame to intervene effectively. Planning requires critical thinking applied through deliberate decision making and problem solving. The nurse avoids setting priorities based solely on physiological factors; other factors should be considered as well. The order of priorities changes as a patient’s condition and needs change, sometimes within a matter of minutes. DIF:Apply (application)REF:241
OBJ: Discuss criteria used in priority setting. TOP: Planning MSC:Management of Care 2. A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.) a. Includes seven domains for level 1 
 b. Uses an easy 3-point Likert scale 
 c. Adds objectivity to judging a patient’s progress 
 d. Allows choice in which interventions to choose 
 e. Measures nursing care on a national and international level 
 ANS: C, E Nursing Outcomes Classification (NOC) links outcomes to NANDA International nursing diagnoses. Such a rating system adds objectivity to judging a patient’s progress. Using standardized nursing terminologies such as NOC makes it more possible to measure aspects of nursing care on a national and international level. The indicators for each NOC outcome allow measurement of the outcomes at any point on a 5-point Likert scale from most negative to most positive. This resource is an option you can use in selecting goals and outcomes (not interventions) for your patients. The Nursing Interventions Classification model includes three levels: domains, classes, and interventions for ease of use. The seven domains are the highest level (level 1) of the model, using broad terms (e.g., safety and basic physiological) to organize the more specific classes and interventions. DIF:Understand (comprehension)REF:244
OBJ:Explain the benefits of using the nursing outcomes classification. TOP:Teaching/LearningMSC:Management of Care Chapter 19: Implementing Nursing Care Chapter 19: Implementing Nursing Care
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse? a. Assessment b. Planning 
 c. Implementation 
 d. Evaluation 
 ANS: C Implementation, the fourth step of the nursing process, formally begins after a nurse develops a plan of care. With a care plan based on clear and relevant nursing diagnoses, a nurse initiates interventions that are designed to assist the patient in achieving the goals and expected outcomes needed to support or improve the patient’s health status. The nurse gathers data during the assessment phase and mutually sets goals and prioritizes care during the planning phase. During the evaluation phase, the nurse determines the achievement of goals and effectiveness of interventions. DIF:Understand (comprehension)REF:257 OBJ: Explain the relationship of implementation to the nursing diagnostic process. TOP: Implementation MSC: Basic Care and Comfort 2. The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching? a. Protocols are guidelines to follow that replace the nursing care plan. 
Protocols assist the clinician in making decisions and choosing interventions for specific health care probl 
 b. conditions. 
 c. Protocols are policies designating each nurse’s duty according to standards of care and a code of ethics. 
 d. Protocols are prescriptive order forms that help individualize the plan of care. 
 ANS: B A clinical practice guideline or protocol is a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations. This guideline establishes interventions for specific health care problems or conditions. The protocol does not replace the nursing care plan. Evidence-based guidelines from protocols can be incorporated into an individualized plan of care. A clinical guideline is not the same as a hospital policy. Standing orders contain orders for the care of a specific group of patients. A protocol is not a prescriptive order form like a standing order. DIF:Understand (comprehension)REF:258
OBJ iscuss the differences between protocols and standing orders. TOP:Teaching/LearningMSC:Management of Care 3. The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next? a. Administer the acetaminophen. 
 b. Notify the health care provider to obtain a verbal order. 
c. Direct the nursing assistive personnel to give the acetaminophen. 
 d. Perform a pain assessment only after administering the acetaminophen. 
 ANS: A A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. The nurse will administer the medication. Notifying the health care provider is not necessary if a standing order exists. The nursing assistive personnel are not licensed to administer medications; therefore, medication administration should not be delegated to this person. A pain assessment should be performed before and after pain medication administration to assess the need for and effectiveness of the medication. DIF:Apply (application)REF:258
OBJ iscuss the differences between protocols and standing orders. TOP: Implementation MSC: Basic Care and Comfort 4. Which action indicates a nurse is using critical thinking for implementation of nursing care to patients? a. Determines whether an intervention is correct and appropriate for the given situation 
 b. Reads over the steps and performs a procedure despite lack of clinical competency 
 c. Establishes goals for a particular patient without assessment 
 d. Evaluates the effectiveness of interventions 
 ANS: A As you implement interventions, use critical thinking to confirm whether the interventions are correct and still appropriate for a patient’s clinical situation. You are responsible for having the necessary knowledge and clinical competency to perform interventions for your patients safely and effectively. The nurse needs to recognize the safety hazards of performing an intervention without clinical competency and seek assistance from another nurse. The nurse cannot evaluate interventions until they are implemented. Patients need ongoing assessment before establishing goals because patient conditions can change very rapidly. DIF:Understand (comprehension)REF:259-260 OBJ: Describe the association between critical thinking and selecting nursing interventions. TOP: Implementation MSC: Basic Care and Comfort 5. A nurse is reviewing a patient’s care plan. Which information will the nurse identify as a nursing intervention? a. The patient will ambulate in the hallway twice this shift using crutches correctly. 
b. Impaired physical mobility related to inability to bear weight on right leg. 
 c. Provide assistance while the patient walks in the hallway twice this shift with crutches. d. The patient is unable to bear weight on right lower extremity. ANS: C Providing assistance to a patient who is ambulating is a nursing intervention. The statement, ―The patient will ambulate in the hallway twice this shift using crutches correctly‖ is a patient
outcome. Impaired physical mobility is a nursing diagnosis. The statement that the patient is unable to bear weight and ambulate can be included with assessment data and is a defining characteristic for the diagnosis of Impaired physical mobility. DIF:Apply (application)REF:257 | 262
OBJ: Explain the relationship of implementation to the nursing diagnostic process. TOP: Implementation MSC: Basic Care and Comfort 6. A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority? a. Assist the patient to walk in the room with crutches. 
 b. Obtain a walker for the patient. 
 c. Consult physical therapy. 
 d. Administer pain medication. 
 ANS: D The patient’s pain is a 7, indicating the priority is pain relief (administer pain medication). Acute pain is the priority because the nurse can address the problem of immobility after the patient receives adequate pain relief. Assisting the patient to walk or obtaining a walker will not address the pain the patient is experiencing. DIF:Analyze (analysis)REF:259-261 | 267
OBJ: Describe the association between critical thinking and selecting nursing interventions. TOP:ImplementationMSC:Management of Care 7. The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing? a. Gathers and organizes needed supplies 
 b. Decides on goals and outcomes for the patient 
 c. Assesses the patient’s readiness for the procedure 
d. Calls for assistance from another nursing staff member 
 ANS: C Always be sure a patient is physically and psychologically ready for any interventions or procedures. After determining the patient’s readiness for the dressing change, the nurse gathers needed supplies. The nurse establishes goals and outcomes before intervening. The nurse needs to ask another staff member to help if necessary after determining readiness of the patient. DIF:Apply (application)REF:261 | 263 | 267 OBJ: Discuss the steps for revising a plan of care before performing implementation. TOP: Implementation MSC: Basic Care and Comfort 8. A patient visiting with family members in the waiting area tells the nurse ―I don’t feel good, especially in the stomach.‖ What should the nurse do? a. Request that the family leave, so the patient can rest. 
 b. Ask the patient to return to the room, so the nurse can inspect the abdomen. 
 c. Ask the patient when the last bowel movement was and to lie down on the sofa. 
 d. Tell the patient that the dinner tray will be ready in 15 minutes and that may help the stomach feel better. 
 ANS: B In this case, the environment needs to be conducive to completing a thorough assessment. A patient’s care environment needs to be safe and conducive to implementing therapies. When you need to expose a patient’s body parts, do so privately by closing room doors or curtains because the patient will then be more relaxed; the patient needs to return to the room for an abdominal assessment for privacy and comfort. The family can remain in the waiting area while the nurse assists the patient back to the room. Beginning the assessment in the waiting area (lie down on the sofa) in the presence of family and other visitors does not promote privacy and patient comfort. Telling the patient that the dinner tray is almost ready is making an assumption that the abdominal discomfort is due to not eating. The nurse needs to perform an assessment first. DIF:Apply (application)REF:260 | 263 OBJ: Select appropriate interventions for a patient. TOP: Implementation MSC:Management of Care 9. A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially? a. Ask for at least two other assistive personnel to come to the room. 
b. Medicate the patient to alleviate discomfort while ambulating. 
 c. Review the patient’s activity orders. 
 d. Offer the patient a walker. 
 ANS: C Before beginning care, review the plan to determine the need for assistance and the type required. Before intervening, the nurse must check the patient’s orders. For example, if the patient is on bed rest, the nurse will need to explain the use of a bedpan rather than helping the patient get out of bed to go to the bathroom. Asking for assistive personnel is appropriate after making sure the patient can get out of bed. If the patient is obese, the nurse will likely need assistance in getting the patient to the bathroom. Medicating the patient before checking the orders is not advised in this situation. Before medicating for pain, the nurse needs to perform a pain assessment. Offering the patient a walker is a premature intervention until the orders are verified. DIF:Apply (application)REF:260 | 263 OBJ: Select appropriate interventions for a patient. TOP: Implementation MSC: Basic Care and Comfort 10. A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take? a. Act as a leader of the health care team. 
 b. Develop good communication skills. 
 c. Work solely with nurses. 
 d. Avoid conflict. 
 ANS: B Good communication between other health care providers builds trust and is related to the acceptance of your role in the health care team. As a beginning nurse, you will not be considered a leader of the health care team, but your input as an interdisciplinary team member is critical. Interdisciplinary involves other health care providers, not just nurses. Organizational culture includes leadership, communication processes, shared beliefs about the quality of clinical guidelines, and conflict resolution. DIF:Apply (application)REF:259
OBJ: Discuss the influence of organizational culture on interdisciplinary collaboration. TOP:ImplementationMSC:Management of Care
11. Which action should the nurse take first during the initial phase of implementation? a. Determine patient outcomes and goals. b. Prioritize patient’s nursing diagnoses. 
 c. Evaluate interventions. 
 d. Reassess the patient. 
 ANS: D Assessment is a continuous process that occurs each time the nurse interacts with a patient. During the initial phase of implementation, reassess the patient. Determining the patient’s goals and prioritizing diagnoses take place in the planning phase before choosing interventions. Evaluation is the last step of the nursing process. DIF:Understand (comprehension)REF:260-261 OBJ: Discuss the steps for revising a plan of care before performing implementation. TOP:ImplementationMSC:Management of Care 12. Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse’s first action? a. Follow the clinical protocol for a stroke. 
 b. Review the most recent lab results for the patient’s potassium level. 
 c. Assess the patient for other symptoms or problems, and then notify the health care provider. 
 d. Administer an antihypertensive medication from the stock supply, and then notify the health care provide 
 ANS: C Communication to other health care professionals must be timely, accurate, and relevant to a patient’s clinical situation. The best answer is to reassess the patient for other symptoms or problems, and then notify the health care provider according to the orders. Reviewing the potassium level does not address the problem of high blood pressure. The nurse does not follow the protocol since the order says to notify the health care provider. The orders read to notify the health care provider, not administer medications. DIF:Apply (application)REF:266
OBJ: Select appropriate interventions for a patient. TOP: Implementation
MSC:Management of Care
13. Which initial intervention is most appropriate for a patient who has a new onset of chest pain? a. Reassess the patient. 
 b. Notify the health care provider. 
c. Administer a prn medication for pain. 
 d. Call radiology for a portable chest x-ray. 
 ANS: A Preparation for implementation ensures efficient, safe, and effective nursing care; the first activity is reassessment. The cause of the patient’s chest pain is unknown, so the patient needs to be reassessed before pain medication is administered or a chest x-ray is obtained. The nurse then notifies the patient’s health care provider of the patient’s current condition in anticipation of receiving further orders. The patient’s chest pain could be due to muscular injury or a pulmonary issue. The nurse needs to reassess first. DIF:Analyze (analysis)REF:261 OBJ: Discuss the steps for revising a plan of care before performing implementation. TOP: Implementation MSC: Basic Care and Comfort 14. A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first? a. Reinforce the wound dressing as needed with 4 × 4 gauze. b. Perform the ordered dressing change twice daily. 
 c. Observe wound appearance and edges. 
 d. Document wound characteristics. 
 ANS: C The most appropriate initial intervention is to assess the wound (observe wound appearance and edges). The nurse must assess the wound first before the findings can be documented, reinforcement of the dressing, and the actual skill of dressing changes. DIF:Apply (application)REF:261 OBJ: Discuss the steps for revising a plan of care before performing implementation. TOP: Implementation MSC: Basic Care and Comfort 15. The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using? a. Cognitive 
 b. Interpersonal 
c. Psychomotor 
 d.Judgmental 
 ANS: B Nursing practice includes cognitive, interpersonal, and psychomotor skills. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly. Cognitive skills include critical thinking and decision-making skills. Psychomotor skill requires the integration of cognitive and motor abilities, such as administering the injection. Being judgmental is not appropriate in nursing; nurses are nonjudgmental. DIF:Apply (application)REF:263-264
OBJ: Define the three implementation skills. TOP: Implementation MSC: Basic Care and Comfort 16. The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using? a. Cognitive 
 b. Interpersonal 
 c. Psychomotor 
 d.Judgmental 
 ANS: C Nursing practice includes cognitive, interpersonal, and psychomotor skills. Psychomotor skill requires the integration of cognitive and motor abilities. The nurse in this example displayed the psychomotor skill of inserting an intravenous catheter while following standards of care and integrating knowledge of anatomy and physiology. Cognitive involves the application of critical thinking and use of good judgment in making sound clinical decisions. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly. DIF:Apply (application)REF:264
OBJ: Define the three implementation skills. TOP: Implementation MSC: Basic Care and Comfort 17. A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? a. ―This system can help medical students determine the cost of the care they provide to patients.‖ 
―If the nursing department uses this system, communication among nurses who work throughout the hosp 
b. be enhanced.‖ 
―We could use this system to help organize orientation for new nursing employees because we can better e 
 c. the nursing interventions we use most frequently on our unit.‖ 
―The NIC system provides one way to improve safe and effective documentation in the hospital’s electron 
 d. record.‖ 
 ANS: A NIC does not help determine the cost of services provided by nurses. The staff development nurse would need to correct this misconception. Because this system is specific to nursing practice, it would not help medical students determine the costs of care. The NIC system developed by the University of Iowa differentiates nursing practice from that of other health care disciplines. All the other statements are true. Benefits of using NIC include enhancing communication among nursing staff and documentation, especially within health information systems such as an electronic documentation system. NIC also helps nurses identify the nursing interventions they implement most frequently. Units that identify routine nursing interventions can use this information to develop checklists for orientation. DIF:Apply (application)REF:259 OBJ iscuss the value of the Nursing Interventions Classification system in documenting nursing care.TOP:Teaching/LearningMSC:Management of Care 18. The nurse is intervening for a family member with role strain. Which direct care nursing intervention is mostappropriate? a. Assisting with activities of daily living 
 b. Counseling about respite care options 
 c. Teaching range-of-motion exercises 
 d. Consulting with a social worker ANS: B Family caregivers need assistance in adjusting to the physical and emotional demands of caregiving. Sometimes they need respite (i.e., a break from providing care). Counseling is an example of a direct care nursing intervention. The other options do not address the identified problem of role strain (activities of daily living and range-of-motion exercises). Consulting is an indirect care nursing intervention. DIF:Apply (application)REF:264-265 OBJ escribe and compare direct and indirect nursing interventions. TOP: Implementation MSC: Psychosocial Integrity 19. The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate? a. Teaches proper handwashing technique 
 b. Properly cleans the patient’s toilet 
 c. Transports urine specimen to the lab 
 d. Informs the oncoming nurse during hand-off 
 ANS: A Teaching proper handwashing technique is a direct care nursing intervention. All the rest are indirect nursing care: cleaning the toilet, transporting specimens, and performing hand-off reports. DIF:Apply (application)REF:264-265
OBJ escribe and compare direct and indirect nursing interventions. TOP: Implementation MSC: Safety and Infection Control 20. The nurse is revising the care plan. In which order will the nurse perform the tasks, beginning with the first step? 1. Revise specific interventions.
2. Revise the assessment column.
3. Choose the evaluation method.
4. Delete irrelevant nursing diagnoses. a. 2, 4, 1, 3 
 b. 4, 2, 1, 3 
 c. 3, 4, 2, 1 
 d. 4, 2, 3, 1 
 ANS: A
Modification of an existing written care plan includes four steps: 1. Revise data in the assessment column to reflect the patient’s current status. Date any new data to inform other members of the health care team of the time that the change occurred. 2. Revise the nursing diagnoses. Delete nursing diagnoses that are no longer relevant and add and date any new diagnoses. Revise related factors and the patient’s goals, outcomes, and priorities. Date any revisions. 3. Revise specific interventions that correspond to the new nursing diagnoses and goals. Be sure that revisions reflect the patient’s present status. 4. Choose the method of evaluation for determining whether you achieved patient outcomes. DIF:Understand (comprehension)REF:261
OBJ: Discuss the steps for revising a plan of care before performing implementation. TOP:ImplementationMSC:Management of Care ULTIPLE RESPONSE 1. A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.) a. Order chest x-ray for suspected arm fracture. 
 b. Prescribe antibiotics for a wound infection. 
 c. Reposition a patient who is on bed rest. 
 d. Teach a patient preoperative exercises. 
 e. Transfer a patient to another hospital unit. 
 ANS: C, D, E A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Repositioning, teaching, and transferring a patient are examples of nursing interventions. Ordering a chest x-ray and prescribing antibiotics are examples of medical interventions performed by a health care provider. DIF:Apply (application)REF:257 | 264 OBJ: Explain the relationship of implementation to the nursing diagnostic process. TOP:ImplementationMSC:Management of Care 2. A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.) a. Ambulating a patient 
 b. Inserting a feeding tube 
 c. Performing resuscitation 
 d. Documenting wound care 
 e. Teaching about medications ANS: A, B, C, E All of the interventions listed (ambulating, inserting a feeding tube, performing resuscitation, and teaching) are direct care interventions involving patient and nurse interaction, except documenting wound care. Documenting wound care is an example of an indirect intervention. DIF:Understand (comprehension)REF:264-265 OBJ escribe and compare direct and indirect nursing interventions. TOP: Implementation MSC: Basic Care and Comfort 3. A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.) a. Equipment 
 b. Safe environment 
 c. Confidence 
 d. Assistive personnel 
 e. Creativity 
 ANS: A, B, D A nurse will organize time and resources in preparation for implementing nursing care. Most nursing procedures require some equipment or supplies. Before performing an intervention, decide which supplies you need and determine their availability. Patient care staff (assistive personnel) work together as patients’ needs demand it. A patient’s care environment needs to be safe and conducive to implementing therapies. Confidence and creativity are needed to provide safe and effective patient care; however, these are critical thinking attitudes, not resources. DIF:Understand (comprehension)REF:261-263 OBJ: Discuss the steps for revising a plan of care before performing implementation. TOP:ImplementationMSC:Management of Care 4. Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.) a. Perform dressing changes twice a day as ordered. 
 b. Teach the patient about signs and symptoms of infection. 
 c. Instruct the family about how to perform dressing changes. 
 d. Gently refocus patient from discussing body image changes. 
 e. Administer medications to control the patient’s blood sugar as ordered. 
 ANS: A, B, C, E Nursing priorities include interventions directed at enhancing wound healing. Teaching the patient about signs and symptoms of infection will help the patient identify signs of appropriate wound healing and know when the need for calling the health care provider arises. Performing dressing changes, controlling blood sugars through administration of medications, and instructing the family in dressing changes all contribute to wound healing. As long as a patient is stable and alert, it is appropriate to allow family to assist with care. The patient should be allowed to discuss body image changes. DIF:Apply (application)REF:262–266
OBJ: Select appropriate interventions for a patient. TOP: Implementation MSC: Basic Care and Comfort Chapter 20: Evaluation Chapter 20: Evaluation
Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting? a. Assessment 
 b. Planning 
 c. Implementation 
 d. Evaluation 
 ANS: D Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient’s condition or well-being improves and if goals have been met. Assessment, the first step of the process, includes data collection. Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and selecting nursing interventions. During implementation, nurses carry out nursing care, which is necessary to help patients achieve their goals. DIF:Understand (comprehension)REF:270 OBJ iscuss the relationship between critical thinking and evaluation. TOP:EvaluationMSC:Management of Care 2. A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next? a. Assessment 
 b. Planning 
 c. Implementation 
 d. Evaluation 
ANS: D Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient’s condition or well-being improves. Assessment involves gathering information about the patient. During the planning phase, patient outcomes are determined. Implementation involves carrying out appropriate nursing interventions. DIF:Understand (comprehension)REF:270-271 OBJ iscuss the relationship between critical thinking and evaluation. TOP:EvaluationMSC:Management of Care 3. A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate? a. ―An evaluation helps you determine whether all nursing interventions were completed.‖ 
 b. ―During evaluation, you determine when to downsize staffing on nursing units.‖ 
 c. ―Nurses use evaluation to determine the effectiveness of nursing care.‖ 
 d. ―Evaluation eliminates unnecessary paperwork and care planning.‖ 
 ANS: C Evaluation is a methodical approach for determining if nursing implementation was effective in influencing a patient’s progress or condition in a favorable way. During evaluation, you do not simply determine whether nursing interventions were completed. The evaluation process is not used to determine when to downsize staffing or how to eliminate paperwork and care planning. DIF:Understand (comprehension)REF:271
OBJ iscuss the relationship between critical thinking and evaluation. TOP:Teaching/LearningMSC:Management of Care 4. After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient’s headache. Which action by the nurse is priority for this patient? a. Eliminate headache from the nursing care plan. 
 b. Direct the nursing assistive personnel to ask if the headache is relieved. 
 c. Reassess the patient’s pain level in 30 minutes. 
 d. Revise the plan of care. 
 ANS: C The nurse’s priority action for this patient is to evaluate whether the nursing intervention of administering acetaminophen was effective. The nurse does not have enough evaluative data at this point to determine whether headache needs to be discontinued. Assessment is the nurse’s responsibility and is not to be delegated to nursing assistive personnel. The nurse does not have enough evaluative data to determine whether the patient’s plan of care needs to be revised. DIF:Apply (application)REF:271 | 275 OBJ: Describe the indicators of a nurse’s ability to evaluate nursing care. TOP: Evaluation MSC: Basic Care and Comfort 5. A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient’s plan of care? a. Determine whether the patient has transportation to get home. 
 b. Evaluate whether patient goals and outcomes have been met. 
 c. Establish whether the patient has a follow-up appointment scheduled. 
 d. Ensure that the patient’s prescriptions have been filled to take home. 
 ANS: B You evaluate whether the results of care match the expected outcomes and goals set for a patient before discontinuing a patient’s plan of care. The patient needs transportation, but that does not address the patient’s mobility status. Whether the patient has a follow-up appointment and ensuring that prescriptions are filled do not evaluate the problem of mobility. DIF:Apply (application)REF:271 | 273
OBJ: Describe how evaluation leads to discontinuation, revision, or modification of a plan of care. TOP:EvaluationMSC:Management of Care 6. The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome? a. The nurse provides assistance while the patient is walking in the hallways. 
 b. The patient is able to ambulate in the hallway with crutches. 
 c. The patient will deny pain while walking in the hallway. 
 d. The patient’s level of mobility will improve. 
 ANS: B The patient’s being able to ambulate in the hallway with crutches is an expected outcome of nursing care. The outcomes of nursing practice are the measurable conditions of patient, family or community status, behavior, or perception. These outcomes are the criteria used to judge success in delivering nursing care. The option stating, ―The patient’s level of mobility will improve‖ is a broader goal statement. The nurse’s assisting a patient to ambulate is an intervention. The patient’s denying pain is an expected outcome for pain, not for physical mobility problems. DIF:Apply (application)REF:270 | 274 OBJ: Explain the relationship among goals of care, expected outcomes, and evaluative measures when evaluating nursing care. TOP: Evaluation MSC: Management of Care 7. The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule? a. Staff documentation of turning the patient every 2 hours 
 b. Presence of redness only on the heels of the patient 
 c. Patient’s eating 100% of all meals 
 d. Absence of skin breakdown 
 ANS: D To determine whether a turning schedule is successful, the nurse needs to assess for the presence of skin breakdown. Redness on any part of the body, including only the patient’s heels, indicates that the turning schedule was not successful. Documentation of interventions does not evaluate whether patient outcomes were met. Eating 100% of meals does not evaluate the effectiveness of a turning schedule. DIF:Analyze (analysis)REF:270 | 272-274 OBJ: Explain the relationship among goals of care, expected outcomes, and evaluative measures when evaluating nursing care. TOP: Evaluation MSC: Basic Care and Comfort 8. A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next? a. Reassess the patient and situation. 
 b. Revise the turning schedule to increase the frequency. 
 c. Delegate turning to the nursing assistive personnel. 
 d. Apply medication to the area of skin that is broken down. 
 ANS: A If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. The nurse must assess before revising, delegating and applying medication. The breakdown may be a result of inadequate nutritional intake and medication cannot be applied unless there is an order. DIF:Apply (application)REF:272 | 275 OBJ: Explain the process of evaluating the outcomes of care for a patient. TOP:EvaluationMSC:Management of Care 9. A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? a. ―Evaluative measures are multiple-page documents used to evaluate nurse performance.‖ 
―Evaluative measures include assessment data used to determine whether patients have met their expected 
 b. outcomes and goals.‖ 
―Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making fro 
 c. novice to expert nurse.‖ 
 d. ―Evaluative measures are objective views for completion of nursing interventions.‖ 
 ANS: B You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed. Evaluative measures are assessment skills and techniques. Evaluative measures are not multiple-page documents, and they are used to assess the patient’s status, not the nurse’s performance or progress from novice to expert. DIF:Understand (comprehension)REF:270-272
OBJ:Explain the importance of using accurate evaluation measures. TOP:Teaching/LearningMSC:Management of Care 10. The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Whichpriority action will the nurse take? a. Ask the nursing assistive personnel if the wound looks better. 
 b. Document the progress of wound healing as ―better‖ in the chart. 
 c. Measure the wound and observe for redness, swelling, or drainage. 
 d. Leave the dressing off the wound for easier access and more frequent assessments. 
ANS: C You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, and patient interview). The nurse performs evaluative measures, such as completing a wound assessment, to evaluate wound healing. Nurses do not delegate assessment to nursing assistive personnel. Documenting ―better‖ is subjective and does not objectively describe the wound. Leaving the dressing off for the nurse’s benefit of easier access is not a part of the evaluation process. DIF:Apply (application)REF:271-272
OBJ:Explain the importance of using accurate evaluation measures. TOP:EvaluationMSC:Management of Care 11. The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the
nurse’s next action? a. Wait and change the dressing at 1800 as ordered. 
 b. Revise the plan of care and change the dressing now. 
 c. Reassess the dressing and the wound in 2 hours. 
 d. Discontinue the plan of care for wound care. 
 ANS: B Because the dressing is saturated and leaking, the nurse needs to revise the plan of care and change the dressing now. Reflection-in-action involves a nurse’s ability to recognize how a patient is responding and then adjusting interventions as a result. A nurse will either change the frequency of an intervention, change how the intervention is delivered, or select a new intervention. Waiting until 1800 or for another 2 hours is not appropriate because assessment data reflect that the dressing is saturated and needs to be changed now. Data are insufficient to support discontinuing the plan of care. Instead, data at this time indicate the need for revision of the plan of care. DIF:Analyze (analysis)REF:271 | 274 | 275 OBJ: Describe how evaluation leads to discontinuation, revision, or modification of a plan of care. TOP: Evaluation MSC: Basic Care and Comfort 12. A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome? a. States feels better after talking with family and friends 
 b. Consumes high-carbohydrate foods when stressed 
c. Dislikes the support group meetings 
 d. Spends most of the day in bed 
 ANS: A Evaluative data that show signs of effective coping will help the nurse determine whether the patient has met the outcome. Talking to family and friends is the only positive option. During evaluation, you perform evaluative measures that allow you to compare clinical data, patient behavior measures, and patient self-report measures collected before implementation with the evaluation findings gathered after administering nursing care. Next, you evaluate whether the results of care match the expected outcomes and goals set for a patient. Consuming highcarbohydrate foods (patient is a diabetic), disliking support group, and spending the day in bed indicate unsuccessful progress toward meeting the patient’s goal. DIF:Apply (application)REF:271 | 273 OBJ:Explain the importance of using accurate evaluation measures. TOP:EvaluationMSC:Management of Care 13. A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate? a. Health status 
 b. Health behavior 
 c. Psychological self-control 
 d. Health service utilization 
 ANS: B Health behavior involves demonstrating a psychomotor skill such as self-injection. Health status is a clinical indicator such as exercise tolerance or blood pressure control. The skill is psychomotor, not psychological self-control. Health service utilization is readmission within 30 days or emergency department use. DIF:Apply (application)REF:272 OBJ:Explain the importance of using accurate evaluation measures. TOP:EvaluationMSC:Management of Care 14. A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal? a. ―I’m worried about what those other girls will think of me.‖ 
b. ―I can’t wear that color. It makes my hips stick out.‖ 
 c. ―I’ll wear the blue dress. It matches my eyes.‖ 
 d. ―I will go to the pool next summer.‖ ANS: C The nurse is evaluating the improvement in body image. The only positive comment made is that the patient is wearing the blue dress to match her eyes. Worrying about others, making my hips stick out, and going to the pool next summer do not reflect positive changes in body image. DIF:Analyze (analysis)REF:271 | 273 OBJ: Explain the relationship among goals of care, expected outcomes, and evaluative measures when evaluating nursing care. TOP: Evaluation MSC: Psychosocial Integrity 15. A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? a. Patient wanders halls at night. 
 b. Patient’s side rails are up with bed alarm activated. 
 c. Patient denies pain while ambulating with assistance. 
 d. Patient correctly states names of family members in the room. 
 ANS: D The goal for this patient would address a decrease or absence of confusion. Thus, one possible sign that a patient’s confusion is improving is seen when a patient can correctly state the names of family members in the room. You examine the results of care by using evaluative measures that relate to goals and expected outcomes. Keeping the side rails up and using a bed alarm are interventions to promote patient safety and prevent falls. The patient’s denying pain indicates positive progress toward resolving pain. The patient’s wandering the halls is a sign of confusion. DIF:Apply (application)REF:270-274
OBJ: Explain the process of evaluating the outcomes of care for a patient. TOP:EvaluationMSC:Management of Care 16. A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse’s priority when evaluating the patient? a. Identify factors interfering with goal achievement. 
b. Counsel the nursing assistive personnel on duty when the patient fell. 
 c. Remove the fall risk sign from the patient’s door because the patient has suffered a fall. 
 d. Request that the more experienced charge nurse complete the documentation about the fall. 
 ANS: A When goals and outcomes are not met, you identify the factors that interfere with their achievement. The nurse identifies factors that interfered with goal achievement to determine the cause of the fall. The fall may not have been due to an error by the nursing assistive personnel; therefore, counseling should be reserved until after the cause has been determined. The patient remains a fall risk, so the fall risk sign should remain on the door. The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation. The charge nurse can be consulted to review the documentation. DIF:Apply (application)REF:275
OBJ: Describe how evaluation leads to discontinuation, revision, or modification of a plan of care. TOP:EvaluationMSC:Management of Care 17. A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal? a. No sputum or cough present in 4 days 
 b. Congestion throughout all lung fields in 2 days 
 c. Shallow, fast respirations 30 breaths per minute in 1 day d. Lungs clear to auscultation following use of inhaler ANS: D In this case, the patient’s goal is to not experience shortness of breath with activity in 3 days. If the lung sounds are clear following use of inhaler, the nurse can determine that the patient is making progress toward achieving the expected outcome. One way for the nurse to evaluate the expected outcome is to assess the patient’s lung sounds. Goals are broad statements that describe changes in a patient’s condition or behavior. Expected outcomes are measurable criteria used to evaluate goal achievement. When an outcome is met, you know that the patient is making progress toward goal achievement. The time frame of 4 days in the first option is not appropriate because this time frame exceeds the time frame stated in the goal. Congestion indicates fluid in the lungs, and a respiratory rate of 30 breaths per minute is elevated/abnormal. This indicates that the patient is still probably experiencing shortness of breath and secretions in the lungs. DIF:Analyze (analysis)REF:272-273 OBJ: Explain the relationship among goals of care, expected outcomes, and evaluative measures when evaluating nursing care. TOP: Evaluation MSC: Management of Care 18. A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met? a. Heart rate 78 beats/min on 12/3 
 b. Heart rate 78 beats/min on 12/4 
 c. Heart rate 80 beats/min on 12/3 
 d. Heart rate 80 beats/min on 12/4 
 ANS: A Heart rate 78 beats/min on 12/3 indicates the goal has been met. Comparing expected and actual findings allows you to interpret and judge a patient’s condition and whether predicted changes have occurred. Expected outcome states less than 80, not 80. The date is by 12/3, not 12/4. DIF:Apply (application)REF:273-274 OBJ: Explain the process of evaluating the outcomes of care for a patient. TOP:EvaluationMSC:Management of Care 19. A nurse is modifying a patient’s care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis.
2. Reassess blood pressure reading.
3. Retake blood pressure after medication.
4. Administer new blood pressure medication.
5. Change goal to blood pressure less than 140/90. a. 1, 5, 2, 4, 3 
 b. 2, 1, 5, 4, 3 
 c. 4, 3, 1, 5, 2 
 d. 5, 4, 5, 1, 2 
 ANS: B If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. After reassessment, determine which nursing diagnoses are accurate for the situation; revise as needed. When revising a care plan, review the goals and expected outcomes for necessary changes after the diagnosis. Then evaluate and revise interventions as needed. DIF:Apply (application)REF:275-276
OBJ: Describe how evaluation leads to discontinuation, revision, or modification of a plan of care. TOP:EvaluationMSC:Management of Care MULTIPLE RESPONSE 1. A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient’s responses to nursing care? (Select all that apply.) a. Observations of wound healing 
 b. Daily blood pressure measurements 
 c. Findings of respiratory rate and depth 
 d. Completion of nursing interventions 
 e. Patient’s subjective report of feelings about a new diagnosis of cancer 
 ANS: A, B, C, E You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, and patient interview). Examples of evaluative measures include assessment of wound healing and respiratory status, blood pressure measurement, and assessment of patient feelings. You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed. DIF:Apply (application)REF:270-272
OBJ:Explain the importance of using accurate evaluation measures. TOP:EvaluationMSC:Management of Care 2. Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) a. Set priorities for patient care. 
 b. Determine whether outcomes or standards are met. 
 c. Ambulate patient 25 feet in the hallway. 
 d. Document results of goal achievement. 
 e. Use self-reflection and correct errors. 
 ANS: B, D, E The expected outcomes established during planning are the standards against which you judge whether goals have been met and if care is successful. You evaluate whether the results of care match the expected outcomes and goals set for a pati [Show More]

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