Nursing Fundamentals for NCLEX: The Only Study Guide You Need To PASS NCLEX Exam (2022)
During the outcome ID and planning step of the nursing process, the nurse works in partnership with the patient and family to do which of the following?
Identify expected patient outcomes, select evidence-based nursing interventions, and communicate the plan of nursing care.
Mr. Price tells the nurse he fears becoming "hooked on drugs" and consequently waits until his pain becomes unbearable before requesting is PRN analgesic. The nurse plans to be more attentive to Mr. Price and to assess his needs for pain management more closely. Which of the following consequences of informal planning ought to be a major concern for the nurse?
The lack of a coordinated plan known by everyone will result in uneven pain management.
When helping Mr. Price turn in bed, the nurse notices that his heels are reddened and plans to place him on precautions for skin breakdown. This is an example of what type of planning?
Ongoing planning, which is problem oriented and has its purpose keeping the plan up to date as new actual or potential problems are Identified.
For the following patient problems, which answer choice lists the problems in order of highest to lowest priority based on Maslow's hierarchy of human needs?
1. Disturbed Body Image
2. Ineffective Airway Clearance
3. Spiritual Distress
4. Impaired Social Interaction
2, 4, 1, 3
From which of the following are nursing outcomes derived?
The problem statement of the nursing diagnosis
Which of the following is an example of an affective outcome?
By 6/12/12, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer (affective outcomes describe changes in patient values, beliefs, and attitudes)
Which of the following is an optional element in a measurable outcome?
"Conditions" - only subject, verb, performance criteria, and target time are mandatory in a measurable outcome.
Which of the following outcomes are correctly written?
1. During the next 24-hour pariod, the patient's fluid intake will total at least 2,000 mL.
2. At the next visit, 12/23/11, the patient will correctly demonstrate relaxation exercises.
Which of the following guidelines for outcome writing are correct?
1. At least one of the outcomes shows a direct resolution of the problem statement in the nursing diagnosis.
2. The patient (and family) values the outcomes.
3. The outcomes are supportive of the total treatment plan.
4. Each outcome is brief and specific (clearly describes one observable, measurable patient behavior/manifestation), is phrased positively, and specifies a time line.
Which of the following are examples of well-stated nursing interventions?
1. Offer patient 60 mL water or juice every 2 hours while awake for a total minimum PO intake of 500 mL.
2. Walk with patient to bathroom for toileting every 2 hours while the patient is awake.