NUR3632 (Foundations)Exam 2 Study
Questions with Solved Solutions
Rated A+ 2026 Updated.
A nurse is planning care for a male adolescent patient who is admitted to the hospital for
treatment of a drug overdose. Which nursing actions are related to the outcome identification
and planning step of the nursing process? Select all that apply.
The nurse formulates nursing diagnoses.
The nurse identifies expected patient outcomes.
The nurse selects evidence-based nursing interventions.
The nurse explains the nursing care plan to the patient.
The nurse assesses the patient's mental status.
The nurse evaluates the patient's outcome achievement. - Answer b, c, d. During the
outcome identification and planning step of the nursing process, the nurse works in partnership
with the patient and family to establish priorities, identify and write expected patient outcomes,
select evidence-based nursing interventions, and communicate the plan of nursing care.
Although all these steps may overlap, formulating and validating nursing diagnoses occurs most
frequently during the diagnosing step of the nursing process. Assessing mental status is part of
the assessment step, and evaluating patient outcomes occurs during the evaluation step of the
nursing process.
A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing
responses to patients in a timely manner. What are examples of this type of planning? Select all
that apply.
A nurse sits down with a patient and prioritizes existing diagnoses.
A nurse assesses a woman for postpartum depression during routine care.
A nurse plans interventions for a patient who is diagnosed with epilepsy.
A busy nurse takes time to speak to a patient who received bad news.
A nurse reassesses a patient whose PRN pain medication is not working.
A nurse coordinates the home care of a patient being discharged. - Answer b, d, e. Informal
planning is a link between identifying a patient's strength or problem and providing an
appropriate nursing response. This occurs, for example, when a busy nurse first recognizes
postpartum depression in a patient, takes time to assess a patient who received bad news about
tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally
planning interventions, and coordinating the home care of a patient being discharged.
3. When helping a patient 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?
Initial planning
Standardized planning
,Ongoing planning
Discharge planning - Answer c. Ongoing planning is problem oriented and has as its purpose
keeping the plan up to date as new actual or potential problems are identified. Initial planning
addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate
patient goals and the related nursing care. Standardized care plans are prepared plans of care
that identify the nursing diagnoses, outcomes, and related nursing interventions common to a
specific population or health problem. During discharge planning, the nurse uses teaching and
counseling skills effectively to help the patient and family develop sufficient knowledge of the
health problem and the therapeutic regimen to carry out necessary self-care behaviors
competently at home.
. A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of
human needs:
(1) Disturbed Body Image
(2) Ineffective Airway Clearance
(3) Spiritual Distress
(4) Impaired Social Interaction
Which answer choice below lists the problems in order of highest priority to lowest priority
based on Maslow's model?
2, 4, 1, 3
3, 1, 4, 2
2, 4, 3, 1
3, 2, 4, 1 - Answer a. 2, 4, 1, 3. Because basic needs must be met before a person can focus
on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1)
physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5)
self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and
belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-
actualization need.
. A nurse is using critical pathway methodology for choosing interventions for a patient who is
receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this
system being used when planning care? Select all that apply.
The nurse uses a minimal practice standard and is able to alter care to meet the patient's
individual needs.
The nurse uses a binary decision tree for stepwise assessment and intervention.
The nurse is able to measure the cause-and-effect relationship between pathway and patient
outcomes.
The nurse uses broad, research-based practice recommendations that may or may not have
been tested in clinical practice.
The nurse uses preprinted provider orders used to expedite the order process after a practice
standard has been validated through research.
,The nurse uses a decision tree that provides intense specificity and no provider flexibility. -
Answer a, c. A critical pathway represents a sequential, interdisciplinary, minimal practice
standard for a specific patient population that provides flexibility to alter care to meet
individualized patient needs. It also offers the ability to measure a cause-and-effect relationship
between pathway and patient outcomes. An algorithm is a binary decision tree that guides
stepwise assessment and intervention with intense specificity and no provider flexibility.
Guidelines are broad, research-based practice recommendations that may or may not have
been tested in clinical practice, and an order set is a preprinted provider order used to expedite
the order process after a practice standard has been validated through analytical research.
A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An
example of an affective outcome for this patient is:
Within 1 day after teaching, the patient will list three benefits of continuing to apply moist
compresses to leg ulcer after discharge.
By 6/12/15, the patient will correctly demonstrate application of wet-to-dry dressing on leg
ulcer.
By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3″ to
2.5″).
By 6/12/15, the patient will verbalize valuing health sufficiently to practice new health
behaviors to prevent recurrence of leg ulcer. - Answer d. Affective outcomes describe
changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in
patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's
achievement of new skills. c is an outcome describing a physical change in the patient.
A nurse is preparing a clinical outcome for a 32-year-old female runner who is recovering from a
stroke that caused right-sided paresis. An example of this type of outcome is:
After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on
the right side of her body.
By 8/15/15, patient will be able to use right arm to dress, comb hair, and feed herself.
Following physical therapy, patient will begin to gradually participate in walking/running events.
By 8/15/15, patient will verbalize feeling sufficiently prepared to participate in running events. -
Answer a. Clinical outcomes describe the expected status of health issues at certain points in
time, after treatment is complete. Functional outcomes (b) describe the person's ability to
function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key
factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes
(d) describe changes in patient values, beliefs, and attitudes.
A nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which
outcome for this patient is correctly written?
Offer the patient 60 mL fluid every 2 hours while awake.
During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL.
Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/15
, At the next visit, 12/23/15, the patient will know that he should drink at least 3 liters of water
per day. - Answer b. The outcomes in a and c make the error of expressing the patient goal
as a nursing intervention. Incorrect: "Offer the patient 60 mL fluid every 2 hours while awake."
Correct: "The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/15." The
outcome in d makes the error of using verbs that are not observable and measurable. Verbs to
be avoided when writing goals include "know," "understand," "learn," and "become aware."
A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68-year-old
male patient. What type of diagnosis does this intervention seek to confirm?
Actual
Possible
Risk
Collaborative - Answer b. An intervention for a possible diagnosis is to collect more patient
data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or
eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on
reducing or eliminating risk factors, and interventions for collaborative problems focus on
monitoring for changes in status and managing these changes with nurse- and physician-
prescribed interventions.
A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement
below is not an example of a well-stated nursing intervention?
Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake
for a total minimum PO intake of 500 mL.
Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each
shift to mark off fluid intake on record at bedside.
Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is
awake.
Manage patient's pain. - Answer . d. This statement lacks sufficient detail to effectively guide
nursing intervention. The set of nursing interventions written to assist a patient to meet an
outcome must be comprehensive. Comprehensive nursing interventions specify what
observations (assessments) need to be made and how often, what nursing interventions need
to be done and when they must be done, and what teaching, counseling, and advocacy needs
patients and families may have.
1. A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due
to multiple fractures from a motor vehicle accident. Which nursing actions are related to this
step in the nursing process? Select all that apply.
The nurse uses the nursing interview to collect patient data.
The nurse analyzes data collected in the nursing assessment.
The nurse develops a care plan for the patient.
The nurse points out the patient's strengths.
The nurse assesses the patient's mental status.
Questions with Solved Solutions
Rated A+ 2026 Updated.
A nurse is planning care for a male adolescent patient who is admitted to the hospital for
treatment of a drug overdose. Which nursing actions are related to the outcome identification
and planning step of the nursing process? Select all that apply.
The nurse formulates nursing diagnoses.
The nurse identifies expected patient outcomes.
The nurse selects evidence-based nursing interventions.
The nurse explains the nursing care plan to the patient.
The nurse assesses the patient's mental status.
The nurse evaluates the patient's outcome achievement. - Answer b, c, d. During the
outcome identification and planning step of the nursing process, the nurse works in partnership
with the patient and family to establish priorities, identify and write expected patient outcomes,
select evidence-based nursing interventions, and communicate the plan of nursing care.
Although all these steps may overlap, formulating and validating nursing diagnoses occurs most
frequently during the diagnosing step of the nursing process. Assessing mental status is part of
the assessment step, and evaluating patient outcomes occurs during the evaluation step of the
nursing process.
A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing
responses to patients in a timely manner. What are examples of this type of planning? Select all
that apply.
A nurse sits down with a patient and prioritizes existing diagnoses.
A nurse assesses a woman for postpartum depression during routine care.
A nurse plans interventions for a patient who is diagnosed with epilepsy.
A busy nurse takes time to speak to a patient who received bad news.
A nurse reassesses a patient whose PRN pain medication is not working.
A nurse coordinates the home care of a patient being discharged. - Answer b, d, e. Informal
planning is a link between identifying a patient's strength or problem and providing an
appropriate nursing response. This occurs, for example, when a busy nurse first recognizes
postpartum depression in a patient, takes time to assess a patient who received bad news about
tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally
planning interventions, and coordinating the home care of a patient being discharged.
3. When helping a patient 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?
Initial planning
Standardized planning
,Ongoing planning
Discharge planning - Answer c. Ongoing planning is problem oriented and has as its purpose
keeping the plan up to date as new actual or potential problems are identified. Initial planning
addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate
patient goals and the related nursing care. Standardized care plans are prepared plans of care
that identify the nursing diagnoses, outcomes, and related nursing interventions common to a
specific population or health problem. During discharge planning, the nurse uses teaching and
counseling skills effectively to help the patient and family develop sufficient knowledge of the
health problem and the therapeutic regimen to carry out necessary self-care behaviors
competently at home.
. A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of
human needs:
(1) Disturbed Body Image
(2) Ineffective Airway Clearance
(3) Spiritual Distress
(4) Impaired Social Interaction
Which answer choice below lists the problems in order of highest priority to lowest priority
based on Maslow's model?
2, 4, 1, 3
3, 1, 4, 2
2, 4, 3, 1
3, 2, 4, 1 - Answer a. 2, 4, 1, 3. Because basic needs must be met before a person can focus
on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1)
physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5)
self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and
belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-
actualization need.
. A nurse is using critical pathway methodology for choosing interventions for a patient who is
receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this
system being used when planning care? Select all that apply.
The nurse uses a minimal practice standard and is able to alter care to meet the patient's
individual needs.
The nurse uses a binary decision tree for stepwise assessment and intervention.
The nurse is able to measure the cause-and-effect relationship between pathway and patient
outcomes.
The nurse uses broad, research-based practice recommendations that may or may not have
been tested in clinical practice.
The nurse uses preprinted provider orders used to expedite the order process after a practice
standard has been validated through research.
,The nurse uses a decision tree that provides intense specificity and no provider flexibility. -
Answer a, c. A critical pathway represents a sequential, interdisciplinary, minimal practice
standard for a specific patient population that provides flexibility to alter care to meet
individualized patient needs. It also offers the ability to measure a cause-and-effect relationship
between pathway and patient outcomes. An algorithm is a binary decision tree that guides
stepwise assessment and intervention with intense specificity and no provider flexibility.
Guidelines are broad, research-based practice recommendations that may or may not have
been tested in clinical practice, and an order set is a preprinted provider order used to expedite
the order process after a practice standard has been validated through analytical research.
A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An
example of an affective outcome for this patient is:
Within 1 day after teaching, the patient will list three benefits of continuing to apply moist
compresses to leg ulcer after discharge.
By 6/12/15, the patient will correctly demonstrate application of wet-to-dry dressing on leg
ulcer.
By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3″ to
2.5″).
By 6/12/15, the patient will verbalize valuing health sufficiently to practice new health
behaviors to prevent recurrence of leg ulcer. - Answer d. Affective outcomes describe
changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in
patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's
achievement of new skills. c is an outcome describing a physical change in the patient.
A nurse is preparing a clinical outcome for a 32-year-old female runner who is recovering from a
stroke that caused right-sided paresis. An example of this type of outcome is:
After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on
the right side of her body.
By 8/15/15, patient will be able to use right arm to dress, comb hair, and feed herself.
Following physical therapy, patient will begin to gradually participate in walking/running events.
By 8/15/15, patient will verbalize feeling sufficiently prepared to participate in running events. -
Answer a. Clinical outcomes describe the expected status of health issues at certain points in
time, after treatment is complete. Functional outcomes (b) describe the person's ability to
function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key
factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes
(d) describe changes in patient values, beliefs, and attitudes.
A nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which
outcome for this patient is correctly written?
Offer the patient 60 mL fluid every 2 hours while awake.
During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL.
Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/15
, At the next visit, 12/23/15, the patient will know that he should drink at least 3 liters of water
per day. - Answer b. The outcomes in a and c make the error of expressing the patient goal
as a nursing intervention. Incorrect: "Offer the patient 60 mL fluid every 2 hours while awake."
Correct: "The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/15." The
outcome in d makes the error of using verbs that are not observable and measurable. Verbs to
be avoided when writing goals include "know," "understand," "learn," and "become aware."
A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68-year-old
male patient. What type of diagnosis does this intervention seek to confirm?
Actual
Possible
Risk
Collaborative - Answer b. An intervention for a possible diagnosis is to collect more patient
data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or
eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on
reducing or eliminating risk factors, and interventions for collaborative problems focus on
monitoring for changes in status and managing these changes with nurse- and physician-
prescribed interventions.
A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement
below is not an example of a well-stated nursing intervention?
Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake
for a total minimum PO intake of 500 mL.
Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each
shift to mark off fluid intake on record at bedside.
Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is
awake.
Manage patient's pain. - Answer . d. This statement lacks sufficient detail to effectively guide
nursing intervention. The set of nursing interventions written to assist a patient to meet an
outcome must be comprehensive. Comprehensive nursing interventions specify what
observations (assessments) need to be made and how often, what nursing interventions need
to be done and when they must be done, and what teaching, counseling, and advocacy needs
patients and families may have.
1. A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due
to multiple fractures from a motor vehicle accident. Which nursing actions are related to this
step in the nursing process? Select all that apply.
The nurse uses the nursing interview to collect patient data.
The nurse analyzes data collected in the nursing assessment.
The nurse develops a care plan for the patient.
The nurse points out the patient's strengths.
The nurse assesses the patient's mental status.
