Solutions - Chapter 13 - Kozier Erb's Fundamentals Nursing - 10 Ed

 

10TYK. Which of the following principles does the nurse use in selecting interventions for the care plan?
1.  Actions should address the etiology of the nursing diagnosis.
2.  Always select independent interventions when possible.
3.  There is one best intervention for each goal/outcome.
Interventions should be “doing,” not just “monitoring.”
Get Solution


1ACT. What assumptions does the nurse make when deciding that using a standardized care plan for Deficient Fluid Volume is appropriate for this client?
Get Solution


1TYK. After being admitted directly to the surgery unit, a 75-year-old client who had elective surgery to replace an arthritic hip was discharged from the postanesthesia recovery unit. The client has been on the orthopedic floor for several hours. Which type of planning will be least useful during the first shift on the orthopedic unit?
1.  Initial
2.  Ongoing
3.  Discharge
4.  Strategic
Get Solution


2ACT. Identify an outcome in the care plan and its nursing intervention that contribute to discharge care planning. What evidence supports your choice?
Get Solution


2TYK. The client with a fractured pelvis requests that family members be allowed to stay overnight in the hospital room. Before determining whether or not this request can be honored, the nurse should consult which of the following?
1.  Hospital policies
2.  Standardized care plans
3.  Orthopedic protocols
4.  Standards of care
Get Solution


3ACT. Consider how the nurse shares the development of the care plan and outcomes with the client.
Get Solution


3TYK. The nurse assesses a postoperative client with an abdominal wound and finds the client drowsy when not aroused. The cli­ent’s pain is ranked 2 on a scale of 0 to 10, vital signs are within preoperative range, extremities are warm with good pulses but skin is very dry. The client declines oral fluids due to nausea, and reports no bowel movement in the past 2 days. Hip dressing is dry with drains intact. Which element is most likely to be considered of high priority for a change in the current care plan?
1.  Pain
2.  Nausea
3.  Constipation
4. Potential for wound infection
Get Solution


4ACT. Not every intervention has a time frame or interval specified. It may be implied. Under what circumstances is this acceptable practice?
Get Solution


4TYK. The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrityrelated to immobility, dry skin, and surgical inci­sion. Which of the following represents a properly stated goal/ outcome? The client will
1.  Turn in bed q2h.
2.  Report the importance of applying lotion to skin daily.
3.  Have intact skin during hospitalization.
4.  Use a pressure-reducing mattress.
Get Solution


5ACT. In Table, Ineffective Airway Clearance is Margaret’s highest priority nursing diagnosis. Under what conditions might this diagnosis be of only moderate priority in Margaret’s case?
Get Solution


6TYK. Place the following activities of planning in the correct order of their use.
1.  Establish goals/outcomes.
2.  Write the care plan.
3.  Set priorities.
4.  Choose interventions.
Get Solution


7TYK. The nurse recognizes which of the following as a benefit of using a standardized care plan?
1.  No individualization is needed.
2.  The nurse chooses from a list of interventions.
3.  They are much shorter than nurse-authored care plans.
4.  They have been approved by accrediting agencies.
Get Solution


8TYK. Which of the following is likely to occur if a goal statement is poorly written?
1.  There is no standard against which to compare outcomes.
2.  The nursing diagnoses cannot be prioritized.
3.  Only dependent nursing interventions can be used.
It is difficult to determine which nursing interventions can be delegated
Get Solution


9TYK. When written properly, NOC outcomes and indicators
1.  Do not require customization.
2.  Address several nursing diagnoses.
3.  Are broad statements of desired end points.
4.  Reflect both the nurse’s and the client’s values.
Get Solution