Exam (elaborations)
Chapter 08 Planning
- Course
- Fundamentals of Nursing
- Institution
- Oxford College Of Emory University
Exam of 11 pages for the course Fundamentals of Nursing at Oxford College Of Emory University (Chapter 08 Planning)
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DAWITChapter 08: Planning
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 3RD Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient who has undergone abdominal surgery. The patient stated
prior to surgery that ―I don‘t think I‘ll be able to handle this if I get a colostomy. I wouldn‘t
know how to manage it.‖ The patient is complaining of severe surgical pain and has an order
for morphine sulfate. The nurse is correct when addressing which Nursing diagnosis first?
a. Pain
b. Alteration in body image
c. Knowledge deficit
d. Risk for falls
ANS: A
Using Maslow‘s hierarchy of needs helps to organize the most-urgent to less-urgent needs.
This framework organizes patient data according to basic human needs common to all
individuals. Maslow‘s theory suggests that basic needs, such as physiologic needs, must be
met before higher needs, such as self-esteem. The nurse also realizes that an actual problem
takes priority over a potential problem. By using the nursing process appropriately, the nurse
correctly chooses the actual, physiological problem first: pain. Once the patient has the
morphine, the risk for falls becomes a higher priority than knowledge deficit or alteration in
body image because the morphine might confuse the patient, cause dizziness or faintness, and
lead to a fall.
N R I G B.C M
U S N TOP:T Planning
O
DIF: Applying OBJ: 8.2
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Care Coordination
2. Setting priorities among identified Nursing diagnoses is the first step in the planning process.
The nurse knows this prioritization includes which action?
a. Monitoring patient responses
b. Carrying out the health care provider‘s plan of care
c. Providing all interventions
d. Collaborating with other disciplines
ANS: A
Setting priorities among identified Nursing diagnoses is the first step in the planning process.
The nurse is responsible for monitoring patient responses, making decisions culminating in a
plan of care, and implementing interventions, including interdisciplinary collaboration and
referral, as needed. The nurse is significantly accountable for achieving the desired outcomes.
DIF: Remembering OBJ: 8.1 TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Care Coordination
3. Which assessment made by the nurse should be addressed first?
a. Reddened area to coccyx
b. Decreased urinary output
, DAWIT
c. Shortness of breath
d. Drainage from surgical incision
ANS: C
It is essential that the nurse identify life-threatening concerns and patient situations that need
to be addressed most quickly. The ABCs—airway, breathing, and circulation—are a valuable
tool for directing the nurse‘s thought process. Depending on the severity of a problem, the
steps of the nursing process may be performed in a matter of seconds.
For instance, if a patient is in respiratory arrest, the most critical goal is for the patient to
begin breathing. The reddened coccyx, decreased urinary output, and surgical incision
drainage are not immediately life threatening.
DIF: Understanding OBJ: 8.2 TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Care Coordination
4. Which patient issue should the nurse address first?
a. Pain
b. Hunger
c. Decreased self-esteem
d. Absence of pulse
ANS: D
It is essential that the nurse identify life-threatening concerns and patient situations that need
to be addressed most quickly. The ABCs—airway, breathing, and circulation—are a valuable
tool for directing the nurse‘s thought process. Depending on the severity of a problem, the
steps of the nursing process may be performed in a matter of seconds. In this situation, the
patient needs CPR immediateNlyUdRuS eI
toNthGeTaB
bs.
enCce M
of a pulse. Pain, hunger, and decreased
self-esteem are not life-threatening issues. Although the nurse must address them,
pulselessness is the priority.
DIF: Understanding OBJ: 8.2 TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Care Coordination
5. The nurse demonstrates a thorough understanding of the planning phase of the nursing process
when making which statement?
a. ―Patients should be included in the planning process.‖
b. ―Patient families should not interfere in the planning process.‖
c. ―The planning process should focus on short-term goals only.‖
d. ―Planning is the first phase of the nursing process.‖
ANS: A
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