Chapter 13 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/E
Chapter 13

Question 1

Type: MCSA

The client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. While the admitting nurse will develop the initial plan of care who will be involved with the ongoing planning of this clients care?

1. The admitting nurse continues to assume that responsible

2. All nurses who work with the client

3. Everybody involved in this clients care

4. The client and the clients support system

Correct Answer: 3

Rationale 1: The continuation of the clients care plan is not the sole responsibility of the admitting nurse.

Rationale 2: While this is true, there is another option that better answers the item.

Rationale 3: Planning is basically the nurses responsibility but input from the client and support persons is essential if a plan is to be effective. In this case, therapies from other disciplines (occupational, physical, speech, etc.) would be involved since the client is in a comprehensive rehabilitation center. The clients support people and caregivers are also going to be involved in the plan of care, but not exclusively.

Rationale 4: While it is important for the client and the clients support people and caregivers be involved in the plan of care, there is an option that better answers this item.

Global Rationale: Page Reference: 215

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 01 Identify activities that occur in the planning process.

Question 2

Type: MCSA

A client is admitted for complications following a routine diagnostic procedure of the colon. The type of care plan that will most likely be implemented for this client is the:

1. Informal nursing care plan

2. Formal nursing care plan

3. Standardized care plan

4. Individualized care plan

Correct Answer: 4

Rationale 1: An informal nursing care plan is a strategy for action that exists only in the nurses mind this does not meet the needs expressed in the item.

Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the clients care this does not meet the needs expressed in the item

Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs.

Rationale 4: An individualized care plan is tailored to meet the unique needs of a specific clientneeds that are not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine proceduresomething that is unplanned and a rare occurrence and must fit with the needs of the client..

Global Rationale: Page Reference: 215

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 03 Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan.

Question 3

Type: MCSA

A client is admitted for a scheduled, elective hip replacement and will be cared for on a unit that specializes in such surgeries. The clients plan of care would most likely be taken from which of the following?

1. Informal nursing care plan

2. Formal nursing care plan

3. Standardized care plan

4. Individualized care plan

Correct Answer: 3

Rationale 1: An informal nursing care plan is a strategy for action that exists in the nurses mind.

Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the clients care.

Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. For example, all clients undergoing hip replacement surgery would have basic, similar needs or problems such as pain, skin integrity disruption, risk for infection, decreased mobility, or risk for fall or injury.

Rationale 4: An individualized care plan is tailored to meet the unique needs of a specific client-needs not addressed by the standardized plan.

Global Rationale: Page Reference: 215

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 03 Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan.

Question 4

Type: MCSA

A nurse is just starting a job at a new hospital. As part of the orientation process, the nurse must review the hospitals policies and procedures for nursing care. Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff for which of the following reasons?

1. Make sure all clients have the same types of care

2. Ensure that minimally accepted standards are met

3. Promote efficient use of the nurses time

4. Eliminate care disparities among clients

Correct Answer: 2,3

Rationale 1: Ensuring that all clients receive the same type of care is not appropriate as care must be individualized to meet the clients needs. Standardized approaches to care planning are common in many health care agencies.

Rationale 2: Ensuring that all clients receive the same type of care is not appropriate as care must be individualized to meet the clients needs. Standardized approaches to care planning are common in many health care agencies.

Rationale 3: Ensuring that all clients receive the same type of care is not appropriate as care must be individualized to meet the clients needs. Standardized approaches to care planning are common in many health care agencies.

Rationale 4: Ensuring that all clients receive the same type of care is not appropriate as care must be individualized to meet the clients needs. Standardized approaches to care planning are common in many health care agencies.

Global Rationale: Page Reference: 215

Cognitive Level: Remembering

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan.

Question 5

Type: MCSA

The neonatal intensive care nurse implements several actions to prevent further complications in a newly admitted, premature infant. The nurse finds these actions in what type of document?

1. Standardized care plan

2. Protocol

3. Standards of care

4. Policy and procedure manual

Correct Answer: 2

Rationale 1: Standardized care plans are preprinted guides for the nursing care of a client who has a need that arises frequently in the agencyor all nursing diagnoses associated with a particular medical condition. In this situation, the nurse is not working from the written care plan, since the baby has just been admitted.

Rationale 2: Protocols are preprinted to indicate the actions commonly required for a particular group of clients (in this case, premature infants). Protocols may include both physicians orders and nursing interventions.

Rationale 3: Standards of care describe nursing actions for clients with similar medical conditions rather than individuals, and they describe achievable rather than ideal nursing care.

Rationale 4: Policies and procedures are developed to govern the handling of frequently occurring situations.

Global Rationale: Page Reference: 217

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 03 Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan.

Question 6

Type: MCSA

When an ICU nurse consults unit policy and administers a routinely used medication to a client admitted to the unit with severe hypotension, this is an example of the nurse implementing which of the following?

1. A STAT order

2. A one-time order

3. A prn order

4. A standing order

Correct Answer: 4

Rationale 1: A STAT order is one that must be carried out immediately.

Rationale 2: A one-time order is for an action to be done only once.

Rationale 3: prn is pro re nataLatin for as needed.

Rationale 4: Standing orders are a written document about policies, rules, regulations, or orders regarding client care.

Global Rationale: Page Reference: 219

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan.

Question 7

Type: MCSA

According to the care plan, the client is to receive chest physiotherapy twice daily. The client lives alone in a rural area, does not drive, and is 40 miles away from a hospital. When setting priorities, the home health nurse will:

1. Make sure that he or she is able to get to the clients home.

2. Assist the client in finding an alternative plan for the achieving the therapys outcomes.

3. Tell the client that this therapy will be impossible to receive.

4. Make arrangements to have the client moved to a long-term care facility.

Correct Answer: 2

Rationale 1: Driving 80 miles two times a day may not be feasible, but perhaps there are other alternatives that could be considered.

Rationale 2: The nurse must consider a variety of factors when assigning priorities, including resources available to the nurse and client. Factors in this case include the distance between the clients home and the hospital and the fact that therapy is ordered on a twice daily basis. Driving 80 miles two times a day may not be feasible, but perhaps there are other alternatives that could be considered (e.g., a neighbor who might be willing to drive the client, or someone in the area who may be able to assist with the therapy).

Rationale 3: Telling the client that the therapy is impossible is premature at this point in time.

Rationale 4: Making arrangements for the client to move is premature at this point in time.

Global Rationale: Page Reference: 221

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 05 Identify factors that the nurse must consider when setting priorities.

Question 8

Type: MCSA

One of the discharge goals for a client is that they will have improved mobility. An appropriately written desired outcome statement is:

1. Client will ambulate without a walker by 6 weeks.

2. Client will ambulate freely in house.

3. Client will not fall.

4. Client will have freer movement in daily activities.

Correct Answer: 1

Rationale 1: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulating without a walker by a certain date is specific as well as measurable.

Rationale 2: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulate freely does not give a time frame, therefore it is not as specific.

Rationale 3: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Goals stated as will not fall are too vague, have no time limit, and do not give the nurse a good set of criteria to evaluate the goal.

Rationale 4: Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulate freely does not give a time frame, therefore it is not as specific.

Global Rationale: Page Reference: 222-223

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 08 Identify guidelines for writing goals/desired outcomes.

Question 9

Type: MCSA

An appropriately written goal statement for the nursing diagnosis Fluid volume deficit, related to active fluid loss, secondary to diarrhea would be:

1. Client will drink more fluids by tomorrow.

2. Client will have good skin turgor.

3. Client will have moist mucous membranes.

4. Client will have intake of at least 1000 mL within 24 hours.

Correct Answer: 4

Rationale 1: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress. Modifiers like more could be more specific.

Rationale 2: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress. Modifiers like good could be more specific, and all options must have a time frame for evaluating the desired performance.

Rationale 3: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progressand all options must have a time frame for evaluating the desired performance.

Rationale 4: The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress. This option includes all necessary components.

Global Rationale: Page Reference: 222-223

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 08 Identify guidelines for writing goals/desired outcomes.

Question 10

Type: MCSA

The nurse understands that the Nursing Outcomes Classification (NOC) taxonomy system can be compared to :

1. Nursing diagnosis statement

2. Planning portion of the care plan

3. Goal statement of the traditional care plan

4. Implementation phase of the care plan

Correct Answer: 3

Rationale 1: The nursing diagnosis statement must follow the NANDA format.

Rationale 2: Goal setting is part of the planning, but the NOC outcome is narrower in use than general planning.

Rationale 3: The Nursing Outcomes Classification (NOC) describes client outcomes that respond to nursing interventions seen in traditional care plans.

Rationale 4: Implementation is compared to the Nursing Interventions Classification (NIC) taxonomy.

Global Rationale: Page Reference: 229

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 07 Discuss the Nursing Outcomes Classification, including an explanation of how to use the outcomes and indicators in care planning.

Question 11

Type: MCSA

Which of the following interventions appropriate for a client with Parkinsons disease who is working to improve fine motor skills would be considered a collaborative intervention?

1. Provide assistance as needed with dressing and grooming.

2. Provide assistive devices and educate client to use grab bar and large handled utensils.

3. Make sure lighting and space are adequate for client.

4. Administer medications to improve muscle tone.

Correct Answer: 2

Rationale 1: Providing assistance and attending to the clients space would be independent interventions.

Rationale 2: Collaborative interventions are actions the nurse carries out with other health team members, such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships between, health personnel. Providing assistive devices and educating on their proper use would fall into the discipline of physical/occupational therapy, although the nurse will have to assist with reinforcing the teaching and information.

Rationale 3: Collaborative interventions are actions the nurse carries out with other health team members, such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships between, health personnel. Providing assistive devices and educating on their proper use would fall into the discipline of physical/occupational therapy, although the nurse will have to assist with reinforcing the teaching and information. P Attending to the clients space would be independent interventions.

Rationale 4: Administering medications would be a dependent intervention.

Global Rationale: Page Reference: 227

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Describe the process of selecting and choosing nursing interventions.

Question 12

Type: MCSA

Which of the following is an example of a dependent nursing intervention?

1. Repositioning the client every 2 hours

2. Assisting the client with transfers to the bathroom

3. Providing ongoing physical assessment, especially of the incisional sites

4. Administering medications for pain

Correct Answer: 4

Rationale 1: This is an example of an independent intervention: those activities that the nurse is licensed to initiate on the basis of knowledge and skills.

Rationale 2: This is an example of an independent intervention: those activities that the nurse is licensed to initiate on the basis of knowledge and skills.

Rationale 3: This is an example of an independent intervention: those activities that the nurse is licensed to initiate on the basis of knowledge and skills.

Rationale 4: Dependent interventions are those activities carried out under the physicians orders or supervision or according to specified routines. The nurse is responsible for assessing the need for and administering medications, but the physician prescribes them.

Global Rationale: Page Reference: 227

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Describe the process of selecting and choosing nursing interventions.

Question 13

Type: MCSA

One of the interventions for a client with a nursing diagnosis of Impaired Swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. The modifier in this intervention is which of the following?

1. 60 to 90 degrees during feeding times

2. Position in chair

3. Upright in a chair

4. Impaired swallowing

Correct Answer: 1

Rationale 1: Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. In this case, defining upright as 60 to 90 degrees and during feeding times gives when this should be done.

Rationale 2: The word position is not descriptive enough for modifiers.

Rationale 3: The word upright is not descriptive enough for modifiers.

Rationale 4: Impaired swallowing is the NANDA label.

Global Rationale: Page Reference: 227

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Describe the process of selecting and choosing nursing interventions.

Question 14

Type: MCSA

A nurse is working with a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Of the following listed, which would be considered an observation intervention?

1. Turn and reposition client every 2 hours.

2. Cushion bony prominences with soft foam while in bed.

3. Provide ongoing assessment for skin breakdown every shift.

4. Apply lotion to dry skin twice daily.

Correct Answer: 3

Rationale 1: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Turning and repositioning would help prevent any further skin breakdown..

Rationale 2: Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Cushioning bony prominences would help prevent any further skin breakdown.

Rationale 3: Observations include assessments made to determine whether a complication is developing as well as observations of the clients responses to nursing and other therapies. Assessment for skin breakdown would fall under this category.

Rationale 4: Application of lotion or other treatments to areas of skin impairment would be considered a treatment intervention.

Global Rationale: Page Reference: 227

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Describe the process of selecting and choosing nursing interventions.

Question 15

Type: MCSA

The most appropriate manner in which to state an intervention directed towards assisting a client with ambulation is:

1. Assist client with ambulation.

2. Ambulate with client, using a gait belt, twice daily for 15 minutes.

3. Make sure client understands the rationale for using the gait belt.

4. Client will ambulate in hallway twice daily.

Correct Answer: 2

Rationale 1: This option lacks some of the required components of a well written intervention.

Rationale 2: A written intervention should include a verb, conditions, and modifiers, plus a time element. Identifying what to do (ambulate), how to do it (with a gait belt), and how long (twice daily for 15 minutes) is the most precise statement.

Rationale 3: This option lacks some of the required components of a well written intervention.

Rationale 4: Client will ambulate in the hallway is a goal statement, not an intervention.

Global Rationale: Page Reference: 227

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Describe the process of selecting and choosing nursing interventions.

Question 16

Type: MCSA

A hospital is implementing the use of NIC (Nursing Interventions Classification) taxonomy. This taxonomy will:

1. Help the nurse with documentation of the care plan.

2. Still require that the nurse use sound judgment and knowledge of the client.

3. Match nursing diagnoses to exact interventions.

4. Help the nurse choose activities that are individualized to the client.

Correct Answer: 2

Rationale 1: The NIC taxonomy may or may not help with documentation.

Rationale 2: The NIC taxonomy, like NOC, is similar to NANDA diagnosesbroadly stated interventions that are standardized in language and generalized in nature. Each nursing diagnosis contains suggestions for several interventions under the NIC taxonomy, and nurses must select the appropriate interventions based on their judgment and knowledge of the client.

Rationale 3: Although it would utilize standard language for all nurses and offer suggestions of interventions for each diagnosis, finding the most appropriate interventions still requires individualization for each client.

Rationale 4: This taxonomy is general and standardized and must be tailored to fit the needs, outcomes, and goals of the individual client.

Global Rationale: Page Reference: 229

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10 Discuss the Nursing Interventions Classification, including an explanation of how to use the interventions and activities in care planning.

Question 17

Type: MCSA

One of the diagnoses formulated for this client who recently experienced a CVA (cerebrovascular accident) is Risk for aspiration, related to neuromuscular dysfunction. Of the following interventions, which includes a rationale?

1. Have suction equipment available at all times.

2. Clear secretions from oral/nasal passageways as needed.

3. Keep client in low-Fowlers position to prevent reflux.

4. Provide frequent assessment for presence of obstructive material in mouth and throat.

Correct Answer: 3

Rationale 1: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain why an intervention would be implemented. This intervention does not explain why it is being done.

Rationale 2: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain why an intervention would be implemented. This intervention does not explain why it is being done.

Rationale 3: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain why an intervention would be implemented. Keeping the client in a position with the head elevated 30 to 45 degrees helps prevent the risk of reflux (food/liquids returning up through the esophagus after having been swallowed).

Rationale 4: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain why an intervention would be implemented. This intervention does not explain why it is being done.

Global Rationale: Page Reference: 219

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Describe the process of selecting and choosing nursing interventions.

Question 18

Type: MCMA

A nurse manager is implementing computerized care plans for the units of the hospital. Which of the following guidelines must be followed when writing care plans?

Standard Text: Select all that apply.

1. Plans must be dated and signed.

2. Categories must have headings.

3. Plans must be specific.

4. Plans must include preventive care and health maintenance.

5. Plans must include interventions for ongoing assessment.

6. Plans are standardized and generalized for all clients.

Correct Answer: 1,2,3,4,5

Rationale 1: This is a recognized guideline when writing care plans.

Rationale 2: This is a recognized guideline when writing care plans.

Rationale 3: This is a recognized guideline when writing care plans.

Rationale 4: This is a recognized guideline when writing care plans.

Rationale 5: This is a recognized guideline when writing care plans.

Rationale 6: Care plans are not both standardized and generalized for all clients.

Global Rationale: Page Reference: 220

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Identify essential guidelines for writing nursing care plans.

Question 19

Type: MCMA

Standards of care, standardized care plans, protocols, policies, and procedures are developed and accepted by the nursing staff for which of the following reasons?

Standard Text: Select all that apply.

1. To make sure all clients have the same type of care.

2. To ensure that minimally accepted standards of care are met.

3. To promote efficient use of the nurses time.

4. To eliminate care disparities among clients.

5. Minimization of healthcare costs.

Correct Answer: 2,3

Rationale 1: While standardized approaches to care planning are common in many healthcare agencies, ensuring that all clients receive the same type of care is not appropriate, as care must be individualized to meet the clients needs.

Rationale 2: Ensuring that minimally accepted standards of care are met is a reason for the actions mentioned in the stem.

Rationale 3: Ensuring that nurses time is used efficiently is a reason for the actions mentioned in the stem.

Rationale 4: Not all clients require the same care, and so disparities are not a concern.

Rationale 5: While cost containment is important, it is not the focus of standardized approaches to care planning.

Global Rationale: Page Reference: 216

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 01 Identify activities that occur in the planning process.
03 Explain how standards of care and predeveloped care plans can be individualized and used in creating a comprehensive nursing care plan.

Question 20

Type: MCMA

A nurse is devising a care plan for a client with complex health issues and current acute health problems. Nursing interventions must meet which of the following criteria?

Standard Text: Select all that apply.

1. Congruent with the clients values, beliefs, and culture.

2. Within established standards of care.

3. Based on scientific and medical knowledge.

4. Achievable with the resources available.

5. Must be safe and appropriate for the clients age.

Correct Answer: 1,2,4,5

Rationale 1: This is a recognized guideline.

Rationale 2: This is a recognized guideline.

Rationale 3: The plan must be based on nursing knowledge and experience or knowledge from relevant sciences (based on rationale).

Rationale 4: This is a recognized guideline.

Rationale 5: This is a recognized guideline.

Global Rationale: Page Reference: 217

Cognitive Level: Understanding

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Describe the process of selecting and choosing nursing interventions.

Question 21

Type: MCMA

The nurse has correctly formatted a clients care when including:

Standard Text: Select all that apply.

1. Ineffective Coping related to drug abuse as evidenced by drug overdose.

2. The client will identify two healthy coping mechanisms by time of discharge.

3. The client has identified two health coping mechanisms to replace inappropriate drug use.

4. The client will be provided with guidance in identifying healthy coping mechanisms.

5. The client has apologized to his family for drug abuse behaviors.

Correct Answer: 1,2,3,4

Rationale 1: The care plan is often organized into sections that include nursing diagnoses.

Rationale 2: The care plan is often organized into sections that include goals/outcomes.

Rationale 3: The care plan is often organized into sections that include evaluations.

Rationale 4: The care plan is often organized into sections that include nursing interventions.

Rationale 5: While this might be a desirable behavior, it is not written as a goal.

Global Rationale: Page Reference: 220-221

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Identify essential guidelines for writing nursing care plans

Question 22

Type: MCMA

When discussing Nursing Intervention Classifications (NIC), the nurse shows an understanding of the role this tool plays in nursing care when stating:

Standard Text: Select all that apply.

1. I can look up interventions according to the nursing diagnosis that Ive selected.

2. The interventions connected to a diagnosis are appropriate for any client with that diagnosis.

3. If there is a NANDA diagnosis, I should be able to find some appropriate interventions.

4. Care plans are best written when the interventions are broad and flexible.

5. I find NIC interventions a really good place to start when Im working on client interventions.

Correct Answer: 1,3,5

Rationale 1: The nurse can look up a clients nursing diagnosis to see which nursing interventions are suggested.

Rationale 2: Each nursing diagnosis contains suggestions for several interventions, so nurses need to select the appropriate interventions based on their judgment and knowledge of the client.

Rationale 3: All NIC interventions have been linked to NANDA nursing diagnostic labels.

Rationale 4: When writing individualized nursing interventions on a care plan, the nurse should record customized activities rather than broad intervention labels.

Rationale 5: Not all activities suggested for the intervention would be needed for every client, so the nurse chooses the activities appropriate for the client and individualizes them to fit the supplies, equipment, and other resources available in the agency.

Global Rationale: Page Reference: 219

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10 Discuss the Nursing Interventions Classification, including an explanation of how to use the interventions and activities in care planning.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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