C HAPTER 18: P LANNING N URSING C ARE
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. A client is newl y diagnosed with diabetes mellitus. The nurse identifies a
nursing diagnosis of knowledge deficient related to new diagnosis and
treatment needs. The most appropriate outcome statement based upon the
established criteria is the following:
A. Client will perform glucose measurements often.
B. Client will app ear less anxious regarding diagnosis.
C. Urinary output will reach normal young adult levels.
D. Client will independentl y perform subcutaneous insulin injection by
8/31.
ANS: D
Client will independentl y perform subcutaneous insulin injection by
8/31. is the most appropriate outcome statement. It addresses the
nursing diagnosis by identifying a singular outcome the client can
realisticall y achieve, is observable, and provides a time frame. Client
will perform glucose measurements often. does not specify a time
frame. Client will appear less anxious regarding diagnosis. is not an
appropriate outcome statement. There is no specific behavior
observable for will appear. Urinary output will reach normal young
adult levels. is not an appropriate outcome statement. It does not
provide a standard against which to measure the clients response to
nursing care, and therefore is not measurable. It is also not time -
limited.
, DIF: A REF: 267 OBJ: Comprehension TOP: Nursing
Process: Planning MSC: NC LEX test plan designation: Health
Promotion and Maintenance
2. Which of the following is the best example of an intermediate prioritized
client need for a client diagnosed with risk of injury related to poor skin
integrity?
A. Appl ying adequate clothing to ensure the clients warmth
B. Providing sufficient quantities of an aloe -based skin lotion
C. Helping the client select her favorite foods from the menu form
D. Dressing the clients feet in non -skid soled slippers when ambulating
ANS: B
An intermediate priorit y is one that involves the non -emergent,
nonlife-threatening needs of the client. Having sufficient aloe -based
lotion is required for maintaining good skin integrit y but is not
required for meeting a life -threatening need. Although the other
options are an intermediate need, they are not th e best option because
they are not directl y related to the clients stated nursing diagnosis.
DIF: C dm 262 OBJ: Anal ysis TOP: Nursing Process: Planning
MSC: NC LEX test plan designation: Health Promotion and
Maintenance
3. Which of the following would be t he best example of a short -term safet y
goal for a client who recentl y experienced abdominal surgery?
A. The client will show no systemic or local signs of infection by time
of discharge from hospital.
, B. The client will demonstrate an understanding of the proper use of
patient-controlled analgesia (PCA).
C. The client will demonstrate effective coughing and deep - breathing
techniques within 2 hours of surgery.
D. The client will consistentl y use the call bell to notify the staff of a
need for assistance to the bathroom upon return to the nursing unit.
ANS: D
Although all the options represent short -term goals, this option
(consistentl y use the call bell to notify the staff) is directl y related to
client safet y because it deals with fall prevention. Although this is
short-term goal (by time of discharge), it is not as directl y related to
safet y as some other options. Although this is short -term goal (time is
inferred by nature of pain needs), it is not as directl y related to safet y
as some other options. Although this i s short-term goal (2 hours), it is
not as directl y related to safet y as some other options.
DIF: C dm 265 OBJ: Anal ysis TOP: Nursing Process: Planning
MSC: NC LEX test plan designation: Health Promotion and
Maintenance
4. Which of the following would be th e most appropriate outcome criterion
for the goal, Clients pain will be managed to within an acceptable level
within 30 minutes of receiving pain medication.
A. Client will deny presence of any pain or discomfort.
B. Client will rate pain at a level of 3 or less out of a possible 10.
C. Client will demonstrate abilit y to request pain medication as
needed.
D. Client will identify two external factors that decrease presence of
pain.
, ANS: B
Client will rate pain at a level of 3 or less out of a possible 10 would
be the most appropriate outcome criterion because it is directly related
to the management of pain levels as reflected by the pain scale. Client
will deny presence of any pain or discomfort does not necessaril y
reflect a reasonable goal. Although client will demo nstrate abilit y to
request pain medication as needed is directed towards pain
management, it does not have the primary focus that evaluating the
pain management intervention has. Client will identify two external
factors that decrease presence of pain is n ot the best option because it
does not directl y relate to pain management but the identification of
contributing factors.
DIF: C dm 266 OBJ: Anal ysis TOP: Nursing Process: Planning
MSC: NC LEX test plan designation: Health Promotion and
Maintenance
5. The nurse is caring for a newl y admitted client who is scheduled for
diagnostic testing in the morning. Which of the following client needs
should take priorit y?
A. Inventory of clothes and other personal belongings
B. Orientation to the nursing unit and individual room
C. Interview regarding medications currently being taken
D. Assessment of body systems for presurgery checklist
ANS: B
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. A client is newl y diagnosed with diabetes mellitus. The nurse identifies a
nursing diagnosis of knowledge deficient related to new diagnosis and
treatment needs. The most appropriate outcome statement based upon the
established criteria is the following:
A. Client will perform glucose measurements often.
B. Client will app ear less anxious regarding diagnosis.
C. Urinary output will reach normal young adult levels.
D. Client will independentl y perform subcutaneous insulin injection by
8/31.
ANS: D
Client will independentl y perform subcutaneous insulin injection by
8/31. is the most appropriate outcome statement. It addresses the
nursing diagnosis by identifying a singular outcome the client can
realisticall y achieve, is observable, and provides a time frame. Client
will perform glucose measurements often. does not specify a time
frame. Client will appear less anxious regarding diagnosis. is not an
appropriate outcome statement. There is no specific behavior
observable for will appear. Urinary output will reach normal young
adult levels. is not an appropriate outcome statement. It does not
provide a standard against which to measure the clients response to
nursing care, and therefore is not measurable. It is also not time -
limited.
, DIF: A REF: 267 OBJ: Comprehension TOP: Nursing
Process: Planning MSC: NC LEX test plan designation: Health
Promotion and Maintenance
2. Which of the following is the best example of an intermediate prioritized
client need for a client diagnosed with risk of injury related to poor skin
integrity?
A. Appl ying adequate clothing to ensure the clients warmth
B. Providing sufficient quantities of an aloe -based skin lotion
C. Helping the client select her favorite foods from the menu form
D. Dressing the clients feet in non -skid soled slippers when ambulating
ANS: B
An intermediate priorit y is one that involves the non -emergent,
nonlife-threatening needs of the client. Having sufficient aloe -based
lotion is required for maintaining good skin integrit y but is not
required for meeting a life -threatening need. Although the other
options are an intermediate need, they are not th e best option because
they are not directl y related to the clients stated nursing diagnosis.
DIF: C dm 262 OBJ: Anal ysis TOP: Nursing Process: Planning
MSC: NC LEX test plan designation: Health Promotion and
Maintenance
3. Which of the following would be t he best example of a short -term safet y
goal for a client who recentl y experienced abdominal surgery?
A. The client will show no systemic or local signs of infection by time
of discharge from hospital.
, B. The client will demonstrate an understanding of the proper use of
patient-controlled analgesia (PCA).
C. The client will demonstrate effective coughing and deep - breathing
techniques within 2 hours of surgery.
D. The client will consistentl y use the call bell to notify the staff of a
need for assistance to the bathroom upon return to the nursing unit.
ANS: D
Although all the options represent short -term goals, this option
(consistentl y use the call bell to notify the staff) is directl y related to
client safet y because it deals with fall prevention. Although this is
short-term goal (by time of discharge), it is not as directl y related to
safet y as some other options. Although this is short -term goal (time is
inferred by nature of pain needs), it is not as directl y related to safet y
as some other options. Although this i s short-term goal (2 hours), it is
not as directl y related to safet y as some other options.
DIF: C dm 265 OBJ: Anal ysis TOP: Nursing Process: Planning
MSC: NC LEX test plan designation: Health Promotion and
Maintenance
4. Which of the following would be th e most appropriate outcome criterion
for the goal, Clients pain will be managed to within an acceptable level
within 30 minutes of receiving pain medication.
A. Client will deny presence of any pain or discomfort.
B. Client will rate pain at a level of 3 or less out of a possible 10.
C. Client will demonstrate abilit y to request pain medication as
needed.
D. Client will identify two external factors that decrease presence of
pain.
, ANS: B
Client will rate pain at a level of 3 or less out of a possible 10 would
be the most appropriate outcome criterion because it is directly related
to the management of pain levels as reflected by the pain scale. Client
will deny presence of any pain or discomfort does not necessaril y
reflect a reasonable goal. Although client will demo nstrate abilit y to
request pain medication as needed is directed towards pain
management, it does not have the primary focus that evaluating the
pain management intervention has. Client will identify two external
factors that decrease presence of pain is n ot the best option because it
does not directl y relate to pain management but the identification of
contributing factors.
DIF: C dm 266 OBJ: Anal ysis TOP: Nursing Process: Planning
MSC: NC LEX test plan designation: Health Promotion and
Maintenance
5. The nurse is caring for a newl y admitted client who is scheduled for
diagnostic testing in the morning. Which of the following client needs
should take priorit y?
A. Inventory of clothes and other personal belongings
B. Orientation to the nursing unit and individual room
C. Interview regarding medications currently being taken
D. Assessment of body systems for presurgery checklist
ANS: B
