Chapter 8: Planning

Which action would the nurse undertake first when beginning to formulate a patient’s plan of care?

a. List possible treatment options

b. Identify realistic outcome indicators

c. Consult with health care team members

d. Rank patient concerns from assessment data

d. Rank patient concerns from assessment data

Which resource is most helpful when prioritizing identified nursing diagnoses?

a. Nursing Interventions Classification (NIC)

b. Gordon’s functional health patterns

c. Maslow’s hierarchy of needs

d. Nursing Outcomes Classification (NOC)

c. Maslow’s hierarchy of needs

If a patient is exhibiting signs and symptoms of each of these nursing diagnoses, which should the nurse address first while planning care?

a. Fatigue

b. Acute pain

c. Lack of Knowledge

d. Disturbed Body Image

b. Acute pain

Which statement illustrates a characteristic of goals within the care planning process?

a. Goals are vague objectives communicating expectations for improvement.

b. Short-term goals need not be measurable, unlike long-term goals.

c. Goal attainment can be measured by identifying nursing interventions.

d. Long-term goals are helpful in judging a patient’s progress.

d. Long-term goals are helpful in judging a patient’s progress.

Which nursing goal is written correctly for a patient with the nursing diagnosis of Risk for Infection after abdominal surgery?

a. Nurse will encourage use of sterile technique during each dressing change.

b. Patient’s white blood count will remain within normal range throughout hospitalization.

c. Patient’s visitors will be instructed in proper handwashing before direct interaction with patient.

d. Patient will understand the importance of cleaning around the incision with a clean cloth during bathing.

b. Patient’s white blood count will remain within normal range throughout hospitalization.

If the nurse chooses the Nursing Outcome Classification (NOC) Appetite for a chemotherapy patient, which outcome indicators would be acceptable for evaluation of goal attainment? (Select all that apply.)

a. Expressed desire to eat

b. Report that food smells good

c. Use of relaxation techniques before meals

d. Preparation of home-cooked meals for self and family

e. Use of nutritional information on labels to guide selections

a. Expressed desire to eat

b. Report that food smells good

Which action by the nurse would be most important in developing a patient-centered plan of care for an alert, oriented adult?

a. Providing a written copy of care options to the patient and family

b. Collaborating with the patient’s social worker to determine resources

c. Listening to the patient’s concerns and beliefs about proposed treatment

d. Engaging the patient’s family, friends, or care providers in conversation

c. Listening to the patient’s concerns and beliefs about proposed treatment

Which interventions can the nurse initiate independently while providing patient care? (Select all that apply.)

a. Ordering a blood transfusion

b. Auscultating lung sounds

c. Monitoring skin integrity

d. Applying heel protectors

e. Adjusting antibiotic dosages

b. Auscultating lung sounds

c. Monitoring skin integrity

d. Applying heel protectors

The nurse notices that a patient is becoming short of breath and anxious. Which interventions are independent nursing actions that do not require the order of a primary care provider? (Select all that apply.)

a. Elevating the head of the patient’s bed

b. Administering oxygen by nasal cannula

c. Assessing the patient’s oxygen saturation

d. Evaluating the patient’s peripheral circulation

a. Elevating the head of the patient’s bed

c. Assessing the patient’s oxygen saturation

d. Evaluating the patient’s peripheral circulation

Which situation indicates the greatest need for collaborative interventions provided by several health care team members?

a. Hospice referral

b. Physical assessment

c. Activities of daily living

d. Health history interview

a. Hospice referral

This situation involves complex care needs that require input from multiple disciplines to ensure comprehensive support and management for patients nearing the end of life.