Nursing Care Plans

1

100

"I am in such pain" "I dont' know anything about breastfeeding" "I am afraid I am going to die"

What are examples of Subjective Data

200

A quick head-to-toe patient assessment:

does not include bladder and bowel output.

includes lab and x-ray results.

includes skin color, turgor, and temperature.

does not include pain status.

includes skin color, turgor, and temperature.

300

Lab values History and physical by MD Old chart Head to toe assessment

What are examples of Objective Data?

400

In the nursing plan of care, expected outcomes should be:

chosen from the approved NANDA-I list.

realistic and attainable.

written based on the medical diagnoses and problems.

written in five words or fewer.

b

Rationale: An expected outcome should be realistic and attainable and should have a defined timeline.

p. 68

500

In an acute care setting, the nursing care plan should be reviewed and updated:

 

once in a while to keep current.

at least once every 24 hours.

once the patient is discharged to home.

no more than once per week.

b

Rationale: The nursing care plan should be constructed right after the admission database is collected. It must be readily available to each nurse who is assigned to the patient. Once every 24 hours, the care plan is re­viewed and updated.

p. 69

2

100

To reflect the patient’s most immediate problems or needs, the list of nursing diagnoses should be:

 

filed.

assessed.

delegated.

prioritized.

d

Rationale: Priorities of care are set so that the most important interventions for the high-priority problems for each patient are attended to first. Then, as time permits, the lower-priority problems are considered.

p. 65

200

NANDA-I

What is the North American Nursing Diagnosis Association-International

300

The nursing history and initial assessment are performed at:

 

change of shift.

discharge.

admission.

physician request.

) c

Rationale: An admission assessment and data collection in­terview (conversation in which facts are obtained) is usually performed when patients are assigned to the nursing unit, enter the care of a home health agency, or become residents in a long-term care facility

p.58

400

What are these?

Grieving

Impaired Physical Mobility

Ineffective Airway Clearance

What are all NANDA diagnoses?

500

Recording pertinent data on the clinical record involves:

 

documentation.

critical thinking.

evaluation.

planning.

a

Rationale: Review the nursing care plan before beginning care to have a clear idea of all of the areas that need docu­mentation (recording of pertinent data in the clinical record).

p. 76

3

100

Priority Setting

What is the ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions?

200

A specific measureable change in a patient's status that you expect to occur in response to nursing care.

What is an expected outcome?

300

Measurable Realistic Time-Limited Observable Mutual Single

What are the criteria for a goal/outcome?

400

Client will ambulate 50 feet with walker daily by the end of week 1. Client will be independent with ambulation up to 100 feet by Christmas vacation.

What are examples of short and long term goals?

500

What is NOC?

What is Nursing Outcomes Classification? A common set of outcomes

4

100

NIC

What is Nursing Interventions Classifications? Standard nursing interventions that have been shown to be effective.

200

The step of the nursing process in which nursing interventions are performed is known as:

 

evaluation.

the rationale.

implementation.

construction.

 

c

Rationale: During the implementation (giving care) phase, the nursing interventions or nursing orders (actions) listed on the nursing care plan are carried out.

p. 73

300

In the nursing process, evaluation is the step in which it is determined if the _____ has been met.

planning

intervention

schedule

goal or expected outcome

d

Rationale: Once the interventions have been carried out, you must determine whether they are effective in helping the patient reach the expected outcomes. If the ex­pected outcomes have been reached, then goals have been met.

p. 76

400

Repositioning a client every 2 hrs to prevent skin breakdown. Listening to a client express fears of dying. Writing down steps for oral suctioning for a client and his family

What are examples of nursing initiated interventions?

500

Taking vital signs Ambulating a patient Helping a client bathe Check if a client is sleeping

What are examples of interventions that can be delegated by the nurse.

5

100

The nursing process component that gathers subjective data from the patient is the:

 

assessment.

priority.

nursing diagnosis.

delegation.

 

a

Rationale: Assessment involves collecting, organizing, documenting, and validating data about a patient’s health status. Assessment data are obtained from the patient, the family, the primary care provider, diagnos­tic tests, and information about the patient from other health professionals.

p. 49

200

What are ways to evaluate if goals/outcomes have been met?

Measure size of a wound. Ask client to list S&S of a wound infection. Have client walk. Have spouse show you how to attach IV infusion.

300

What are reasons why goals/outcomes are not met?

Client did not agree to the goal Wrong diagnosis was selected by nurse Goal was not measurable

400

A physician’s order is needed to:

discontinue the nursing plan of care.

administer medication.

discontinue a nursing intervention or action.

change a nursing diagnosis.

b

Rationale: Administering a medication is a dependent nursing action because it requires a primary care provider’s order.

p. 74

500

What is the final aspect of the evaluation step?

Documentation of goals met or unmet.