NUR3632 FOUNDATIONS EXAM 2
STUDY
A6nurse6is6planning6care6for6a6male6adolescent6patient6who6is6admitted6to6the6hospital6fo
r6treatment6of6a6drug6overdose.6Which6nursing6actions6are6related6to6the6outcome6identifi
cation6and6planning6step6of6the6nursing6process?6Select6all6that6apply.
The6nurse6formulates6nursing6diagnoses.
The6nurse6identifies6expected6patient6outcomes.
The6nurse6selects6evidence-based6nursing6interventions.
The6nurse6explains6the6nursing6care6plan6to6the6patient.
The6nurse6assesses6the6patient's6mental6status.
The6nurse6evaluates6the6patient's6outcome6achievement.6-
6b,6c,6d.6During6the6outcome6identification6and6planning6step6of6the6nursing6process,6the6
nurse6works6in6partnership6with6the6patient6and6family6to6establish6priorities,6identify6and6
write6expected6patient6outcomes,6select6evidence-
based6nursing6interventions,6and6communicate6the6plan6of6nursing6care.6Although6all6the
se6steps6may6overlap,6formulating6and6validating6nursing6diagnoses6occurs6most6freque
ntly6during6the6diagnosing6step6of6the6nursing6process.6Assessing6mental6status6is6part6o
f6the6assessment6step,6and6evaluating6patient6outcomes6occurs6during6the6evaluation6st
ep6of6the6nursing6process.
A6nurse6on6a6busy6surgical6unit6relies6on6informal6planning6to6provide6appropriate6nursin
g6responses6to6patients6in6a6timely6manner.6What6are6examples6of6this6type6of6planning?
6Select6all6that6apply.
A6nurse6sits6down6with6a6patient6and6prioritizes6existing6diagnoses.
A6nurse6assesses6a6woman6for6postpartum6depression6during6routine6care.
A6nurse6plans6interventions6for6a6patient6who6is6diagnosed6with6epilepsy.
A6busy6nurse6takes6time6to6speak6to6a6patient6who6received6bad6news.
A6nurse6reassesses6a6patient6whose6PRN6pain6medication6is6not6working.
A6nurse6coordinates6the6home6care6of6a6patient6being6discharged.6-
6b,6d,6e.6Informal6planning6is6a6link6between6identifying6a6patient's6strength6or6problem6an
d6providing6an6appropriate6nursing6response.6This6occurs,6for6example,6when6a6busy6nur
se6first6recognizes6postpartum6depression6in6a6patient,6takes6time6to6assess6a6patient6wh
o6received6bad6news6about6tests,6or6reassesses6a6patient6for6pain.6Formal6planning6invol
,ves6prioritizing6diagnoses,6formally6planning6interventions,6and6coordinating6the6home6c
are6of6a6patient6being6discharged.
3.6When6helping6a6patient6turn6in6bed,6the6nurse6notices6that6his6heels6are6reddened6and
6plans6to6place6him6on6precautions6for6skin6breakdown.6This6is6an6example6of6what6type6
of6planning?
Initial6planning
Standardized6planning
Ongoing6planning
Discharge6planning6-
6c.6Ongoing6planning6is6problem6oriented6and6has6as6its6purpose6keeping6the6plan6up6to6
date6as6new6actual6or6potential6problems6are6identified.6Initial6planning6addresses6each6
problem6listed6in6the6prioritized6nursing6diagnoses6and6identifies6appropriate6patient6goal
s6and6the6related6nursing6care.6Standardized6care6plans6are6prepared6plans6of6care6that6
identify6the6nursing6diagnoses,6outcomes,6and6related6nursing6interventions6common6to6
a6specific6population6or6health6problem.6During6discharge6planning,6the6nurse6uses6teac
hing6and6counseling6skills6effectively6to6help6the6patient6and6family6develop6sufficient6kn
owledge6of6the6health6problem6and6the6therapeutic6regimen6to6carry6out6necessary6self-
care6behaviors6competently6at6home.
.6A6nurse6is6prioritizing6the6following6patient6diagnoses6according6to6Maslow's6hierarchy6
of6human6needs:
(1)6Disturbed6Body6Image
(2)6Ineffective6Airway6Clearance
(3)6Spiritual6Distress
(4)6Impaired6Social6Interaction
Which6answer6choice6below6lists6the6problems6in6order6of6highest6priority6to6lowest6priorit
y6based6on6Maslow's6model?
2,64,61,63
3,61,64,62
2,64,63,61
3,62,64,616-
6a.62,64,61,63.6Because6basic6needs6must6be6met6before6a6person6can6focus6on6higher6on
es,6patient6needs6may6be6prioritized6according6to6Maslow's6hierarchy:6(1)6physiologic6ne
eds,6(2)6safety6needs,6(3)6love6and6belonging6needs,6(4)6self-esteem6needs,6and6(5)6self-
actualization6needs.6#26is6an6example6of6a6physiologic6need,6#46is6an6example6of6a6love6
and6belonging6need,6#16is6an6example6of6a6self-
esteem6need,6and6#36is6an6example6of6a6self-actualization6need.
.6A6nurse6is6using6critical6pathway6methodology6for6choosing6interventions6for6a6patient6
who6is6receiving6chemotherapy6for6breast6cancer.6Which6nursing6actions6are6characteris
tics6of6this6system6being6used6when6planning6care?6Select6all6that6apply.
The6nurse6uses6a6minimal6practice6standard6and6is6able6to6alter6care6to6meet6the6patient'
s6individual6needs.
The6nurse6uses6a6binary6decision6tree6for6stepwise6assessment6and6intervention.
,The6nurse6is6able6to6measure6the6cause-and-
effect6relationship6between6pathway6and6patient6outcomes.
The6nurse6uses6broad,6research-
based6practice6recommendations6that6may6or6may6not6have6been6tested6in6clinical6practi
ce.
The6nurse6uses6preprinted6provider6orders6used6to6expedite6the6order6process6after6a6pr
actice6standard6has6been6validated6through6research.
The6nurse6uses6a6decision6tree6that6provides6intense6specificity6and6no6provider6flexibilit
y.6-
6a,6c.6A6critical6pathway6represents6a6sequential,6interdisciplinary,6minimal6practice6stand
ard6for6a6specific6patient6population6that6provides6flexibility6to6alter6care6to6meet6individua
lized6patient6needs.6It6also6offers6the6ability6to6measure6a6cause-and-
effect6relationship6between6pathway6and6patient6outcomes.6An6algorithm6is6a6binary6deci
sion6tree6that6guides6stepwise6assessment6and6intervention6with6intense6specificity6and6
no6provider6flexibility.6Guidelines6are6broad,6research-
based6practice6recommendations6that6may6or6may6not6have6been6tested6in6clinical6practi
ce,6and6an6order6set6is6a6preprinted6provider6order6used6to6expedite6the6order6process6af
ter6a6practice6standard6has6been6validated6through6analytical6research.
A6nurse6is6identifying6outcomes6for6a6patient6who6has6a6leg6ulcer6related6to6diabetes.6An6
example6of6an6affective6outcome6for6this6patient6is:
Within616day6after6teaching,6the6patient6will6list6three6benefits6of6continuing6to6apply6moist
6compresses6to6leg6ulcer6after6discharge.
By66/12/15,6the6patient6will6correctly6demonstrate6application6of6wet-to-
dry6dressing6on6leg6ulcer.
By66/19/15,6the6patient's6ulcer6will6begin6to6show6signs6of6healing6(e.g.,6size6shrinks6from
63″6to62.5″).
By66/12/15,6the6patient6will6verbalize6valuing6health6sufficiently6to6practice6new6health6be
haviors6to6prevent6recurrence6of6leg6ulcer.6-
6d.6Affective6outcomes6describe6changes6in6patient6values,6beliefs,6and6attitudes.6Cogniti
ve6outcomes6(a)6describe6increases6in6patient6knowledge6or6intellectual6behaviors;6psyc
homotor6outcomes6(b)6describe6the6patient's6achievement6of6new6skills.6c6is6an6outcome6
describing6a6physical6change6in6the6patient.
A6nurse6is6preparing6a6clinical6outcome6for6a632-year-
old6female6runner6who6is6recovering6from6a6stroke6that6caused6right-
sided6paresis.6An6example6of6this6type6of6outcome6is:
After6receiving636weeks6of6physical6therapy,6patient6will6demonstrate6improved6moveme
nt6on6the6right6side6of6her6body.
By68/15/15,6patient6will6be6able6to6use6right6arm6to6dress,6comb6hair,6and6feed6herself.
Following6physical6therapy,6patient6will6begin6to6gradually6participate6in6walking/
running6events.
By68/15/15,6patient6will6verbalize6feeling6sufficiently6prepared6to6participate6in6running6ev
ents.6-
6a.6Clinical6outcomes6describe6the6expected6status6of6health6issues6at6certain6points6in6ti
me,6after6treatment6is6complete.6Functional6outcomes6(b)6describe6the6person's6ability6to
, 6function6in6relation6to6the6desired6usual6activities.6Quality-of-
life6outcomes6(c)6focus6on6key6factors6that6affect6someone's6ability6to6enjoy6life6and6achi
eve6personal6goals.6Affective6outcomes6(d)6describe6changes6in6patient6values,6beliefs,6
and6attitudes.
A6nurse6is6caring6for6an6elderly6male6patient6who6is6receiving6fluids6for6dehydration.6Whic
h6outcome6for6this6patient6is6correctly6written?
Offer6the6patient6606mL6fluid6every626hours6while6awake.
During6the6next624-hour6period,6the6patient's6fluid6intake6will6total6at6least62,0006mL.
Teach6the6patient6the6importance6of6drinking6enough6fluids6to6prevent6dehydration6by61/
15/15
At6the6next6visit,612/23/15,6the6patient6will6know6that6he6should6drink6at6least636liters6of6w
ater6per6day.6-
6b.6The6outcomes6in6a6and6c6make6the6error6of6expressing6the6patient6goal6as6a6nursing6i
ntervention.6Incorrect:6"Offer6the6patient6606mL6fluid6every626hours6while6awake."6Correct
:6"The6patient6will6drink6606mL6fluid6every626hours6while6awake,6beginning61/3/15."6The6o
utcome6in6d6makes6the6error6of6using6verbs6that6are6not6observable6and6measurable.6Ve
rbs6to6be6avoided6when6writing6goals6include6"know,"6"understand,"6"learn,"6and6"becom
e6aware."
A6nurse6is6collecting6more6patient6data6to6confirm6a6diagnosis6of6emphysema6for6a668-
year-old6male6patient.6What6type6of6diagnosis6does6this6intervention6seek6to6confirm?
Actual
Possible
Risk
Collaborative6-
6b.6An6intervention6for6a6possible6diagnosis6is6to6collect6more6patient6data6to6confirm6or6r
ule6out6the6problem.6An6intervention6for6an6actual6diagnosis6is6to6reduce6or6eliminate6con
tributing6factors6to6the6diagnosis.6Interventions6for6a6risk6diagnosis6focus6on6reducing6or6
eliminating6risk6factors,6and6interventions6for6collaborative6problems6focus6on6monitoring
6for6changes6in6status6and6managing6these6changes6with6nurse-6and6physician-
prescribed6interventions.
A6nurse6is6caring6for6a6patient6who6is6diagnosed6with6congestive6heart6failure.6Which6stat
ement6below6is6not6an6example6of6a6well-stated6nursing6intervention?
Offer6patient6606mL6water6or6juice6(prefers6orange6or6cranberry6juice)6every626hours6whil
e6awake6for6a6total6minimum6PO6intake6of65006mL.
Teach6patient6the6necessity6of6carefully6monitoring6fluid6intake6and6output;6remind6patien
t6each6shift6to6mark6off6fluid6intake6on6record6at6bedside.
Walk6with6patient6to6bathroom6for6toileting6every626hours6(on6even6hours)6while6patient6is
6awake.
Manage6patient's6pain.6-
6.6d.6This6statement6lacks6sufficient6detail6to6effectively6guide6nursing6intervention.6The6s
et6of6nursing6interventions6written6to6assist6a6patient6to6meet6an6outcome6must6be6compr
ehensive.6Comprehensive6nursing6interventions6specify6what6observations6(assessment
s)6need6to6be6made6and6how6often,6what6nursing6interventions6need6to6be6done6and6whe
STUDY
A6nurse6is6planning6care6for6a6male6adolescent6patient6who6is6admitted6to6the6hospital6fo
r6treatment6of6a6drug6overdose.6Which6nursing6actions6are6related6to6the6outcome6identifi
cation6and6planning6step6of6the6nursing6process?6Select6all6that6apply.
The6nurse6formulates6nursing6diagnoses.
The6nurse6identifies6expected6patient6outcomes.
The6nurse6selects6evidence-based6nursing6interventions.
The6nurse6explains6the6nursing6care6plan6to6the6patient.
The6nurse6assesses6the6patient's6mental6status.
The6nurse6evaluates6the6patient's6outcome6achievement.6-
6b,6c,6d.6During6the6outcome6identification6and6planning6step6of6the6nursing6process,6the6
nurse6works6in6partnership6with6the6patient6and6family6to6establish6priorities,6identify6and6
write6expected6patient6outcomes,6select6evidence-
based6nursing6interventions,6and6communicate6the6plan6of6nursing6care.6Although6all6the
se6steps6may6overlap,6formulating6and6validating6nursing6diagnoses6occurs6most6freque
ntly6during6the6diagnosing6step6of6the6nursing6process.6Assessing6mental6status6is6part6o
f6the6assessment6step,6and6evaluating6patient6outcomes6occurs6during6the6evaluation6st
ep6of6the6nursing6process.
A6nurse6on6a6busy6surgical6unit6relies6on6informal6planning6to6provide6appropriate6nursin
g6responses6to6patients6in6a6timely6manner.6What6are6examples6of6this6type6of6planning?
6Select6all6that6apply.
A6nurse6sits6down6with6a6patient6and6prioritizes6existing6diagnoses.
A6nurse6assesses6a6woman6for6postpartum6depression6during6routine6care.
A6nurse6plans6interventions6for6a6patient6who6is6diagnosed6with6epilepsy.
A6busy6nurse6takes6time6to6speak6to6a6patient6who6received6bad6news.
A6nurse6reassesses6a6patient6whose6PRN6pain6medication6is6not6working.
A6nurse6coordinates6the6home6care6of6a6patient6being6discharged.6-
6b,6d,6e.6Informal6planning6is6a6link6between6identifying6a6patient's6strength6or6problem6an
d6providing6an6appropriate6nursing6response.6This6occurs,6for6example,6when6a6busy6nur
se6first6recognizes6postpartum6depression6in6a6patient,6takes6time6to6assess6a6patient6wh
o6received6bad6news6about6tests,6or6reassesses6a6patient6for6pain.6Formal6planning6invol
,ves6prioritizing6diagnoses,6formally6planning6interventions,6and6coordinating6the6home6c
are6of6a6patient6being6discharged.
3.6When6helping6a6patient6turn6in6bed,6the6nurse6notices6that6his6heels6are6reddened6and
6plans6to6place6him6on6precautions6for6skin6breakdown.6This6is6an6example6of6what6type6
of6planning?
Initial6planning
Standardized6planning
Ongoing6planning
Discharge6planning6-
6c.6Ongoing6planning6is6problem6oriented6and6has6as6its6purpose6keeping6the6plan6up6to6
date6as6new6actual6or6potential6problems6are6identified.6Initial6planning6addresses6each6
problem6listed6in6the6prioritized6nursing6diagnoses6and6identifies6appropriate6patient6goal
s6and6the6related6nursing6care.6Standardized6care6plans6are6prepared6plans6of6care6that6
identify6the6nursing6diagnoses,6outcomes,6and6related6nursing6interventions6common6to6
a6specific6population6or6health6problem.6During6discharge6planning,6the6nurse6uses6teac
hing6and6counseling6skills6effectively6to6help6the6patient6and6family6develop6sufficient6kn
owledge6of6the6health6problem6and6the6therapeutic6regimen6to6carry6out6necessary6self-
care6behaviors6competently6at6home.
.6A6nurse6is6prioritizing6the6following6patient6diagnoses6according6to6Maslow's6hierarchy6
of6human6needs:
(1)6Disturbed6Body6Image
(2)6Ineffective6Airway6Clearance
(3)6Spiritual6Distress
(4)6Impaired6Social6Interaction
Which6answer6choice6below6lists6the6problems6in6order6of6highest6priority6to6lowest6priorit
y6based6on6Maslow's6model?
2,64,61,63
3,61,64,62
2,64,63,61
3,62,64,616-
6a.62,64,61,63.6Because6basic6needs6must6be6met6before6a6person6can6focus6on6higher6on
es,6patient6needs6may6be6prioritized6according6to6Maslow's6hierarchy:6(1)6physiologic6ne
eds,6(2)6safety6needs,6(3)6love6and6belonging6needs,6(4)6self-esteem6needs,6and6(5)6self-
actualization6needs.6#26is6an6example6of6a6physiologic6need,6#46is6an6example6of6a6love6
and6belonging6need,6#16is6an6example6of6a6self-
esteem6need,6and6#36is6an6example6of6a6self-actualization6need.
.6A6nurse6is6using6critical6pathway6methodology6for6choosing6interventions6for6a6patient6
who6is6receiving6chemotherapy6for6breast6cancer.6Which6nursing6actions6are6characteris
tics6of6this6system6being6used6when6planning6care?6Select6all6that6apply.
The6nurse6uses6a6minimal6practice6standard6and6is6able6to6alter6care6to6meet6the6patient'
s6individual6needs.
The6nurse6uses6a6binary6decision6tree6for6stepwise6assessment6and6intervention.
,The6nurse6is6able6to6measure6the6cause-and-
effect6relationship6between6pathway6and6patient6outcomes.
The6nurse6uses6broad,6research-
based6practice6recommendations6that6may6or6may6not6have6been6tested6in6clinical6practi
ce.
The6nurse6uses6preprinted6provider6orders6used6to6expedite6the6order6process6after6a6pr
actice6standard6has6been6validated6through6research.
The6nurse6uses6a6decision6tree6that6provides6intense6specificity6and6no6provider6flexibilit
y.6-
6a,6c.6A6critical6pathway6represents6a6sequential,6interdisciplinary,6minimal6practice6stand
ard6for6a6specific6patient6population6that6provides6flexibility6to6alter6care6to6meet6individua
lized6patient6needs.6It6also6offers6the6ability6to6measure6a6cause-and-
effect6relationship6between6pathway6and6patient6outcomes.6An6algorithm6is6a6binary6deci
sion6tree6that6guides6stepwise6assessment6and6intervention6with6intense6specificity6and6
no6provider6flexibility.6Guidelines6are6broad,6research-
based6practice6recommendations6that6may6or6may6not6have6been6tested6in6clinical6practi
ce,6and6an6order6set6is6a6preprinted6provider6order6used6to6expedite6the6order6process6af
ter6a6practice6standard6has6been6validated6through6analytical6research.
A6nurse6is6identifying6outcomes6for6a6patient6who6has6a6leg6ulcer6related6to6diabetes.6An6
example6of6an6affective6outcome6for6this6patient6is:
Within616day6after6teaching,6the6patient6will6list6three6benefits6of6continuing6to6apply6moist
6compresses6to6leg6ulcer6after6discharge.
By66/12/15,6the6patient6will6correctly6demonstrate6application6of6wet-to-
dry6dressing6on6leg6ulcer.
By66/19/15,6the6patient's6ulcer6will6begin6to6show6signs6of6healing6(e.g.,6size6shrinks6from
63″6to62.5″).
By66/12/15,6the6patient6will6verbalize6valuing6health6sufficiently6to6practice6new6health6be
haviors6to6prevent6recurrence6of6leg6ulcer.6-
6d.6Affective6outcomes6describe6changes6in6patient6values,6beliefs,6and6attitudes.6Cogniti
ve6outcomes6(a)6describe6increases6in6patient6knowledge6or6intellectual6behaviors;6psyc
homotor6outcomes6(b)6describe6the6patient's6achievement6of6new6skills.6c6is6an6outcome6
describing6a6physical6change6in6the6patient.
A6nurse6is6preparing6a6clinical6outcome6for6a632-year-
old6female6runner6who6is6recovering6from6a6stroke6that6caused6right-
sided6paresis.6An6example6of6this6type6of6outcome6is:
After6receiving636weeks6of6physical6therapy,6patient6will6demonstrate6improved6moveme
nt6on6the6right6side6of6her6body.
By68/15/15,6patient6will6be6able6to6use6right6arm6to6dress,6comb6hair,6and6feed6herself.
Following6physical6therapy,6patient6will6begin6to6gradually6participate6in6walking/
running6events.
By68/15/15,6patient6will6verbalize6feeling6sufficiently6prepared6to6participate6in6running6ev
ents.6-
6a.6Clinical6outcomes6describe6the6expected6status6of6health6issues6at6certain6points6in6ti
me,6after6treatment6is6complete.6Functional6outcomes6(b)6describe6the6person's6ability6to
, 6function6in6relation6to6the6desired6usual6activities.6Quality-of-
life6outcomes6(c)6focus6on6key6factors6that6affect6someone's6ability6to6enjoy6life6and6achi
eve6personal6goals.6Affective6outcomes6(d)6describe6changes6in6patient6values,6beliefs,6
and6attitudes.
A6nurse6is6caring6for6an6elderly6male6patient6who6is6receiving6fluids6for6dehydration.6Whic
h6outcome6for6this6patient6is6correctly6written?
Offer6the6patient6606mL6fluid6every626hours6while6awake.
During6the6next624-hour6period,6the6patient's6fluid6intake6will6total6at6least62,0006mL.
Teach6the6patient6the6importance6of6drinking6enough6fluids6to6prevent6dehydration6by61/
15/15
At6the6next6visit,612/23/15,6the6patient6will6know6that6he6should6drink6at6least636liters6of6w
ater6per6day.6-
6b.6The6outcomes6in6a6and6c6make6the6error6of6expressing6the6patient6goal6as6a6nursing6i
ntervention.6Incorrect:6"Offer6the6patient6606mL6fluid6every626hours6while6awake."6Correct
:6"The6patient6will6drink6606mL6fluid6every626hours6while6awake,6beginning61/3/15."6The6o
utcome6in6d6makes6the6error6of6using6verbs6that6are6not6observable6and6measurable.6Ve
rbs6to6be6avoided6when6writing6goals6include6"know,"6"understand,"6"learn,"6and6"becom
e6aware."
A6nurse6is6collecting6more6patient6data6to6confirm6a6diagnosis6of6emphysema6for6a668-
year-old6male6patient.6What6type6of6diagnosis6does6this6intervention6seek6to6confirm?
Actual
Possible
Risk
Collaborative6-
6b.6An6intervention6for6a6possible6diagnosis6is6to6collect6more6patient6data6to6confirm6or6r
ule6out6the6problem.6An6intervention6for6an6actual6diagnosis6is6to6reduce6or6eliminate6con
tributing6factors6to6the6diagnosis.6Interventions6for6a6risk6diagnosis6focus6on6reducing6or6
eliminating6risk6factors,6and6interventions6for6collaborative6problems6focus6on6monitoring
6for6changes6in6status6and6managing6these6changes6with6nurse-6and6physician-
prescribed6interventions.
A6nurse6is6caring6for6a6patient6who6is6diagnosed6with6congestive6heart6failure.6Which6stat
ement6below6is6not6an6example6of6a6well-stated6nursing6intervention?
Offer6patient6606mL6water6or6juice6(prefers6orange6or6cranberry6juice)6every626hours6whil
e6awake6for6a6total6minimum6PO6intake6of65006mL.
Teach6patient6the6necessity6of6carefully6monitoring6fluid6intake6and6output;6remind6patien
t6each6shift6to6mark6off6fluid6intake6on6record6at6bedside.
Walk6with6patient6to6bathroom6for6toileting6every626hours6(on6even6hours)6while6patient6is
6awake.
Manage6patient's6pain.6-
6.6d.6This6statement6lacks6sufficient6detail6to6effectively6guide6nursing6intervention.6The6s
et6of6nursing6interventions6written6to6assist6a6patient6to6meet6an6outcome6must6be6compr
ehensive.6Comprehensive6nursing6interventions6specify6what6observations6(assessment
s)6need6to6be6made6and6how6often,6what6nursing6interventions6need6to6be6done6and6whe
