This is a comprehensive and detailed practice material/testbank that contains practice questions and answers on chapter 18; planning nursing care for Nur 130.
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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.
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.
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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.
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
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