NUR3632 Foundations Exam 2 Study
A nurse is planning care for a male adolescent patient who is admitted to the
hospital for treatment of a drug overdose. Which nursing actions are related to
the outcome identification and planning step of the nursing process? Select all
that apply.
The nurse formulates nursing diagnoses.
The nurse identifies expected patient outcomes.
The nurse selects evidence-based nursing interventions.
The nurse explains the nursing care plan to the patient.
The nurse assesses the patient's mental status.
The nurse evaluates the patient's outcome achievement. - correct answer
✔b, c, d. During the outcome identification and planning step of the nursing
process, the nurse works in partnership with the patient and family to establish
priorities, identify and write expected patient outcomes, select evidence-based
nursing interventions, and communicate the plan of nursing care. Although all
these steps may overlap, formulating and validating nursing diagnoses occurs
most frequently during the diagnosing step of the nursing process. Assessing
mental status is part of the assessment step, and evaluating patient outcomes
occurs during the evaluation step of the nursing process.
A nurse on a busy surgical unit relies on informal planning to provide
appropriate nursing responses to patients in a timely manner. What are
examples of this type of planning? Select all that apply.
A nurse sits down with a patient and prioritizes existing diagnoses.
A nurse assesses a woman for postpartum depression during routine care.
A nurse plans interventions for a patient who is diagnosed with epilepsy.
A busy nurse takes time to speak to a patient who received bad news.
A nurse reassesses a patient whose PRN pain medication is not working.
,A nurse coordinates the home care of a patient being discharged. - correct
answer ✔b, d, e. Informal planning is a link between identifying a patient's
strength or problem and providing an appropriate nursing response. This
occurs, for example, when a busy nurse first recognizes postpartum
depression in a patient, takes time to assess a patient who received bad news
about tests, or reassesses a patient for pain. Formal planning involves
prioritizing diagnoses, formally planning interventions, and coordinating the
home care of a patient being discharged.
3. When helping a patient turn in bed, the nurse notices that his heels are
reddened and plans to place him on precautions for skin breakdown. This is
an example of what type of planning?
Initial planning
Standardized planning
Ongoing planning
Discharge planning - correct answer ✔c. Ongoing planning is problem
oriented and has as its purpose keeping the plan up to date as new actual or
potential problems are identified. Initial planning addresses each problem
listed in the prioritized nursing diagnoses and identifies appropriate patient
goals and the related nursing care. Standardized care plans are prepared
plans of care that identify the nursing diagnoses, outcomes, and related
nursing interventions common to a specific population or health problem.
During discharge planning, the nurse uses teaching and counseling skills
effectively to help the patient and family develop sufficient knowledge of the
health problem and the therapeutic regimen to carry out necessary self-care
behaviors competently at home.
. A nurse is prioritizing the following patient diagnoses according to Maslow's
hierarchy of human needs:
(1) Disturbed Body Image
(2) Ineffective Airway Clearance
(3) Spiritual Distress
,(4) Impaired Social Interaction
Which answer choice below lists the problems in order of highest priority to
lowest priority based on Maslow's model?
2, 4, 1, 3
3, 1, 4, 2
2, 4, 3, 1
3, 2, 4, 1 - correct answer ✔a. 2, 4, 1, 3. Because basic needs must be met
before a person can focus on higher ones, patient needs may be prioritized
according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3)
love and belonging needs, (4) self-esteem needs, and (5) self-actualization
needs. #2 is an example of a physiologic need, #4 is an example of a love and
belonging need, #1 is an example of a self-esteem need, and #3 is an
example of a self-actualization need.
. A nurse is using critical pathway methodology for choosing interventions for
a patient who is receiving chemotherapy for breast cancer. Which nursing
actions are characteristics of this system being used when planning care?
Select all that apply.
The nurse uses a minimal practice standard and is able to alter care to meet
the patient's individual needs.
The nurse uses a binary decision tree for stepwise assessment and
intervention.
The nurse is able to measure the cause-and-effect relationship between
pathway and patient outcomes.
The nurse uses broad, research-based practice recommendations that may or
may not have been tested in clinical practice.
The nurse uses preprinted provider orders used to expedite the order process
after a practice standard has been validated through research.
The nurse uses a decision tree that provides intense specificity and no
provider flexibility. - correct answer ✔a, c. A critical pathway represents a
sequential, interdisciplinary, minimal practice standard for a specific patient
population that provides flexibility to alter care to meet individualized patient
, needs. It also offers the ability to measure a cause-and-effect relationship
between pathway and patient outcomes. An algorithm is a binary decision tree
that guides stepwise assessment and intervention with intense specificity and
no provider flexibility. Guidelines are broad, research-based practice
recommendations that may or may not have been tested in clinical practice,
and an order set is a preprinted provider order used to expedite the order
process after a practice standard has been validated through analytical
research.
A nurse is identifying outcomes for a patient who has a leg ulcer related to
diabetes. An example of an affective outcome for this patient is:
Within 1 day after teaching, the patient will list three benefits of continuing to
apply moist compresses to leg ulcer after discharge.
By 6/12/15, the patient will correctly demonstrate application of wet-to-dry
dressing on leg ulcer.
By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g., size
shrinks from 3″ to 2.5″).
By 6/12/15, the patient will verbalize valuing health sufficiently to practice new
health behaviors to prevent recurrence of leg ulcer. - correct answer ✔d.
Affective outcomes describe changes in patient values, beliefs, and attitudes.
Cognitive outcomes (a) describe increases in patient knowledge or intellectual
behaviors; psychomotor outcomes (b) describe the patient's achievement of
new skills. c is an outcome describing a physical change in the patient.
A nurse is preparing a clinical outcome for a 32-year-old female runner who is
recovering from a stroke that caused right-sided paresis. An example of this
type of outcome is:
After receiving 3 weeks of physical therapy, patient will demonstrate improved
movement on the right side of her body.
By 8/15/15, patient will be able to use right arm to dress, comb hair, and feed
herself.
Following physical therapy, patient will begin to gradually participate in
walking/running events.
