Question 1

The nurse is creating a comprehensive patient plan of care. Which information does the nurse include?

Accepted Answer

A)  Methods of performing patient activities of daily living (ADLs) 
B)  Both medical and nursing interventions
C)  Reasons for assigning care personnel
D)  Symptoms of patient's medical diagnosis B

Question 2

The nurse is reviewing the goals set on a patient's plan of care. Which description specifically differentiates short-term goals from long-term goals? Short-term goals:

Accepted Answer

A)  Can be met within a few hours or a few days.
B)  Flow from the problem side of the nursing diagnosis.
C)  Must have target times with dates.
D)  Specify desired patient responses to interventions. A

Question 3

The nurse is planning care for a patient by using a standardized care plan for Impaired Walking, related to left-side weakness. Which activity will the nurse perform when individualizing the plan for the patient?

Accepted Answer

A)  Validating conflicting data with the patient
B)  Transcribing medical orders
C)  Stating the frequency for ambulation
D)  Performing a comprehensive assessment C

Question 4

A client arrives in the emergency department and is pale and breathing rapidly. The client immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the client and decides the first series of actions needed. Which type of planning is the nurse demonstrating?

Accepted Answer

A)  Formal planning
B)  Informal planning
C)  Ongoing planning
D)  Initial planning

Question 5

The nurse is providing care for a patient following a total-knee replacement. The patient is to remain in acute care for two days. When developing an individualized plan of care for this patient, which goals set by the nurse are considered to be short-term? Select all that apply.

Accepted Answer

A)  Patient will ambulate 10 feet with assistance 5 hours after surgery.
B)  Patient will exhibit the ability to use a walker when ambulating.
C)  Patient will understand the signs of infection at the surgery site.
D)  Patient will experience a pain level of 4 or below on a 0-to-10 scale.
E)  Patient will voice understanding of pain management at home.

Question 6

The nurse recognizes which client as having the greatest need for comprehensive formal discharge planning?

Accepted Answer

A)  A postpartum patient after the birth to her second child, who lives with her spouse and 18-month-old daughter
B)  A patient who is readmitted for exacerbation of chronic obstructive pulmonary disease (COP
D)  
C)  A patient who is 12-years of age being discharged home with a parent after outpatient surgery
D)  An adult patient just diagnosed with renal failure who is scheduled to start peritoneal dialysis

Question 7

A nurse is overheard complaining about the time used to develop patients' plans of care. Which information does the nurse manager share with the nurse about the importance of the process? Select all that apply.

Accepted Answer

A)  Ensures that provided care is complete
B)  Supports of continuity of care among nurses and between shifts
C)  Promotes the efficient use of nursing efforts and care activities
D)  Provides nurses with a guide for assessment and documentation
E)  Meets the requirements set by accrediting agencies regarding care

Question 8

In which manner does the nurse understand that NANDA-I problem labels and Nursing Outcome Classification (NOC) outcome labels are alike?

Accepted Answer

A)  Health status is expressed in terms of human responses.
B)  Patient response is expressed before interventions are done.
C)  Patient responses are always expressed in positive terms.
D)  Both methods reveal patterns of related cues.

Question 9

The nurse is formulating a plan of care for an older client admitted for dehydration. The nurse develops goals from a standardized care plan and the physician's medical orders. Which nurse-sensitive goal is appropriate for this patient?

Accepted Answer

A)  Ask the patient about oral fluid preferences.
B)  Maintain a full water pitcher at the patient's bedside.
C)  Ensure patient's oral intake is 100 mL/hour during the day.
D)  Keep the patient on strict intake and output (I&O)  monitoring.

Question 10

The nurse is individualizing a client's plan of care for the nursing diagnosis Anxiety. For which reason does the nurse write goals/outcomes on the plan of care?

Accepted Answer

A)  To recognize desirable changes related to formulated interventions
B)  To monitor specific patient responses to medical interventions
C)  To identify specific nursing behaviors to improve a patient's health
D)  To utilize criteria to evaluate the appropriateness of a nursing diagnosis

Question 11

A nurse is providing care for an older adult patient of Asian heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association (ANA) standards for outcomes identification? Select all that apply.

Accepted Answer

A)  Developing culturally appropriate outcomes
B)  Using the standardized outcomes on the clinical pathway
C)  Choosing the best outcome for the patient, regardless of the cost
D)  Involving the patient and family in formulating the outcomes
E)  Advocating for the patient regarding unwanted treatment or healthcare

Question 12

The nurse asks the nurse manager, "What do initial planning, ongoing planning, and discharge planning have in common?" Which information from the nurse manager is correct?

Accepted Answer

A)  They are based on assessment and diagnosis.
B)  They focus on the patient's perception of needs.
C)  They require input from a multidisciplinary team.
D)  They have specific time lines in which to be completed.

Question 13

The nurse writes a nursing diagnosis for a patient, which states, "Impaired Memory, related to fluid and electrolyte imbalances, as manifested by (AMB) inability to express knowledge of recent events." Which essential goal/outcome does the nurse include on the care plan?

Accepted Answer

A)  Current medications are reviewed for mind-altering side effects.
B)  Patient demonstrates using techniques to help with memory loss.
C)  Oral fluid intake of at a minimum of 1,500 mL of fluid per day.
D)  Electrolyte supplements will be taken, as prescribed, with meals.

Question 14

The nurse is updating a patient plan of care. Which outcome statement, written by the nurse, contains the best example of performance criteria?

Accepted Answer

A)  Patient turns self in bed frequently while awake
B)  Patient understands how to use crutches by day two
C)  Patient states that pain is decreased after being medicated
D)  Patient eats 75% of each meal without complaint of nausea

Question 15

The nurse in an acute care facility is preparing to discharge an older client to an extended care facility. Which objectives does the nurse address in preparation for a comprehensive discharge process for this client? Select all that apply.

Accepted Answer

A)  Maintain interagency communication
B)  Determine level of family involvement
C)  Share information about financial status
D)  Activities for maintaining functional ability
E)  Current ability for performing self-care needs

Question 16

The nurse is developing a plan of care for a patient following surgery, and plans to include collaborative interventions. Which definition of goal/outcome is applicable for collaborative problems?

Accepted Answer

A)  Collaborative problems are monitored only by other disciplines.
B)  Collaborative problems are usually affected by nursing interventions.
C)  Collaborative problems state that a complication will not occur.
D)  Collaborative problems state only broad performance criteria.

Question 17

The nurse is working on a new nursing unit that utilizes preprinted standardized care plans along with comprehensive care plans developed by the nurse. Which is the most important advantage for the use of both types of care plans?

Accepted Answer

A)  Helps ensure that important interventions for the diagnosis are not overlooked
B)  May prescribe care for one or more nursing diagnosis or medical conditions
C)  Includes nursing interventions along with multidisciplinary interventions
D)  Promotes a consistency of care among patients with similar conditions

Question 18

The nurse is working on development of a plan of care for a patient hospitalized for a respiratory infection. Which is the best example of an outcome statement for this patient?

Accepted Answer

A)  Uses the incentive spirometer when awake
B)  Walks two times in the hall during day and evening shift
C)  Maintains oxygen saturation above 92% while performing activities of daily living (ADLs) 
D)  Tolerates 10 sets of range-of-motion exercises with physical therapy

Question 19

Newly hired nurses on an acute care unit are encouraged to utilize computerized care planning in providing patient care. Which advantages exist from this process? Select all that apply.

Accepted Answer

A)  The computer stores nursing diagnoses, medical diagnoses, and individualized interventions.
B)  The computer generates a diagnosis and desired outcome after the patient's assessment is entered.
C)  The computer is capable of generating a list of suggested interventions, the nursing diagnosis, and goals.
D)  The computer promotes the development and refinement of nursing intuition, insight, or expertise.
E)  The computer prompts the nurse to consider a variety of actions and decreases overlooking common and important interventions.

Exam 5: Planning Outcomes