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:PlanningMSC: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:Discuss the difference between a goal and an expected outcome.

TOP:PlanningMSC: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:Discuss the difference between a goal and an expected outcome.

TOP:PlanningMSC: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:PlanningMSC: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?

a.

Risk for impaired skin integrity

b.

Risk for infection

c.

Spiritual distress

d.

Reflex urinary incontinence

ANS: D

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:PlanningMSC:Management of Care

14. A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk 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:PlanningMSC:Management of Care

15. A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired 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:PlanningMSC:Management of Care

16. A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most 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:PlanningMSC: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:Describe 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