1ATI PN PEDIATRICS PROCTORED EXAM
(Detail Solutions)
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.
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 2Nurses 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.
3.Which information indicates a nurse has a good understanding of a goal?
It is a statement describing the patient’s accomplishments without a
a.time restriction.
It is a realistic statement predicting any negative responses to
b.treatments.
It is a broad statement describing a desired change in a patient’s
c.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.
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. Patient will use the walker correctly to ambulate to the bathroom as
c.needed.
Patient will use a sliding board correctly to transfer to the bedside
d.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 3goals, 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.
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?
The patient will verbalize a decreased pain level less than 3 on a 0 to
a.10 scale by the end of this shift.
The patient will demonstrate increased tolerance to activity over the
b.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.
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.
The nurse will monitor the patient’s heart rhythm continuously this
b.shift.
The patient will feed self at all mealtimes today without reports of
c.shortness of breath.
The nurse will administer pain medication every 4 hours to keep the
d.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
(Detail Solutions)
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.
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 2Nurses 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.
3.Which information indicates a nurse has a good understanding of a goal?
It is a statement describing the patient’s accomplishments without a
a.time restriction.
It is a realistic statement predicting any negative responses to
b.treatments.
It is a broad statement describing a desired change in a patient’s
c.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.
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. Patient will use the walker correctly to ambulate to the bathroom as
c.needed.
Patient will use a sliding board correctly to transfer to the bedside
d.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 3goals, 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.
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?
The patient will verbalize a decreased pain level less than 3 on a 0 to
a.10 scale by the end of this shift.
The patient will demonstrate increased tolerance to activity over the
b.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.
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.
The nurse will monitor the patient’s heart rhythm continuously this
b.shift.
The patient will feed self at all mealtimes today without reports of
c.shortness of breath.
The nurse will administer pain medication every 4 hours to keep the
d.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
