Foundations Potter and Perry Chapter 18-
Planning Nursing Care
1. The nurse completes a thorough assessment of a patient and analyzes the data to
identify nursing diagnoses. Which step will the nurse take next in the nursing process?
a.
Assessment
b.
Diagnosis
c.
Planning
d.
Implementation - ANS c
2. A patient's plan of care includes the goal of increasing mobility this shift. As the patient is
ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which
initial action will the nurse take next to revise the plan of care?
a.
Consult physical therapy.
b.
Establish a new plan of care.
, c.
Set new priorities for the patient.
d.
Assess the patient. - ANS d
3. Which information indicates a nurse has a good understanding of a goal?
a.
It is a statement describing the patient's accomplishments without a time restriction.
b.
It is a realistic statement predicting any negative responses to treatments.
c.
It is a broad statement describing a desired change in a patient's behavior.
d.
It is a measurable change in a patient's physical state. - ANS C
4. A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which
goal statement is realistic for the nurse to assign to this patient?
a.
Patient will increase activity level this shift.
b.
Patient will turn side to back to side with assistance every 2 hours.
Planning Nursing Care
1. The nurse completes a thorough assessment of a patient and analyzes the data to
identify nursing diagnoses. Which step will the nurse take next in the nursing process?
a.
Assessment
b.
Diagnosis
c.
Planning
d.
Implementation - ANS c
2. A patient's plan of care includes the goal of increasing mobility this shift. As the patient is
ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which
initial action will the nurse take next to revise the plan of care?
a.
Consult physical therapy.
b.
Establish a new plan of care.
, c.
Set new priorities for the patient.
d.
Assess the patient. - ANS d
3. Which information indicates a nurse has a good understanding of a goal?
a.
It is a statement describing the patient's accomplishments without a time restriction.
b.
It is a realistic statement predicting any negative responses to treatments.
c.
It is a broad statement describing a desired change in a patient's behavior.
d.
It is a measurable change in a patient's physical state. - ANS C
4. A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which
goal statement is realistic for the nurse to assign to this patient?
a.
Patient will increase activity level this shift.
b.
Patient will turn side to back to side with assistance every 2 hours.
