04C - Planning Nursing Care - The Nursing
Process
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The nurse is working with a client 1 The client's request would be of low priority
who is being prepared for a because it is not directly related to a specific illness
diagnostic test this afternoon. The or prognosis. An unmet need is not the most
client tells the nurse that she wants appropriate label for the client's request. The
to have her hair shampooed. Which client's request is not an intermediate priority. An
of the following is the most intermediate priority is one that involves the non-
appropriate label with regard to emergent, non-life-threatening needs of the client.
prioritizing her request? The client's request is not a safety & security need;
1. Low priority the outcome does not threaten her well-being.
2. An unmet need
3. Intermediate priority
4. A safety & security need
,Assuming that all of the following are 1 Long-term goals focus on prevention,
realistic, a long-term goal for a client rehabilitation, discharge, & health education. An
that is a tailor by trade & has been appropriate long-term goal for this client would be
admitted for eye surgery should for rehabilitation & the client's return to occupation,
include: in this case sewing. Preventing ocular infection is a
1. Returning to sewing short-term goal. A short-term goal is expected to
2. Preventing ocular infection be achieved within a short time, usually in less than
3. Administering eye drops on time in 1 week. In 1 weeks' time, the client's risk for infection
the hospital should be greatly reduced. Administering eye
4. Performing independent hygienic drops on time in the hospital is a short-term goal.
care in the hospital Long-term goals are usually designed for problem
resolution after discharge, especially from an acute
care setting. Performing independent hygienic care
in the hospital is a short-term goal. Long-term
goals are usually made for problem resolution after
discharge, especially from an acute care setting.
The nurse writes the following goal 4 "Client will have a 7 AM blood pressure reading
for a client who is hypertensive: less than 140/90" would be the most appropriate
"Client will maintain a blood pressure outcome criterion. It is clientcentered, singular,
within acceptable limits." Which of observable, measurable, time-limited, & realistic.
the following would be the most "Client will request pain medication as needed"
appropriate outcome criterion? does not allow the nurse to be able to determine if
1. "Client will request pain medication change has taken place. It would be more
as needed." measurable to state the client will rate pain below
2. "Client will experience no 4 on a scale of 0 to 10 by 24 hours. "Client will
headache or dizziness." experience no headache or dizziness" is not time-
3. "Client will identify at least two limited. "Client will identify at least two things that
things that cause stress." cause stress" is not time-limited or singular.
4. "Client will have a 7 AM blood
pressure reading less than 140/90."
, Nursing interventions may be 4 Preparing a client for a diagnostic test is an
categorized based upon the degree example of a physician-initiated intervention.
of nursing autonomy. Which of the Teaching a client to administer his or her insulin
following nursing interventions is injection is an example of a nurse-initiated
considered as physician- or intervention. Assisting a new mother with breast-
prescriber-initiated? feeding is an example of a nurse-initiated
1. Teaching a client to administer his intervention. Notifying a nutritionist of a client's
or her insulin injection dietary preferences is a collaborative intervention.
2. Assisting a new mother with
learning the art of breast-feeding
3. Notifying the nutritionist of a
client's specific dietary preferences
4. Administering a cleansing enema
in preparation for radiological testing
Nursing interventions should be 3 The intervention statement does not include how
documented according to specific frequently the warm soaks should be applied. The
criteria in order that they may be method is applying warm, wet soaks to the patient's
clearly understood by other leg while awake. The quantity is warm, wet soaks.
members of the nursing team. The The qualification of the person who will perform
intervention statement "Nurse will the action is the designation of "the nurse."
apply warm, wet soaks to the
patient's leg while awake" lacks
which of the following components?
1. Method
2. Quantity
3. Frequency
4. Performing staff
Process
Leave the first rating
Save
Terms in this set (39) Hide definitions
The nurse is working with a client 1 The client's request would be of low priority
who is being prepared for a because it is not directly related to a specific illness
diagnostic test this afternoon. The or prognosis. An unmet need is not the most
client tells the nurse that she wants appropriate label for the client's request. The
to have her hair shampooed. Which client's request is not an intermediate priority. An
of the following is the most intermediate priority is one that involves the non-
appropriate label with regard to emergent, non-life-threatening needs of the client.
prioritizing her request? The client's request is not a safety & security need;
1. Low priority the outcome does not threaten her well-being.
2. An unmet need
3. Intermediate priority
4. A safety & security need
,Assuming that all of the following are 1 Long-term goals focus on prevention,
realistic, a long-term goal for a client rehabilitation, discharge, & health education. An
that is a tailor by trade & has been appropriate long-term goal for this client would be
admitted for eye surgery should for rehabilitation & the client's return to occupation,
include: in this case sewing. Preventing ocular infection is a
1. Returning to sewing short-term goal. A short-term goal is expected to
2. Preventing ocular infection be achieved within a short time, usually in less than
3. Administering eye drops on time in 1 week. In 1 weeks' time, the client's risk for infection
the hospital should be greatly reduced. Administering eye
4. Performing independent hygienic drops on time in the hospital is a short-term goal.
care in the hospital Long-term goals are usually designed for problem
resolution after discharge, especially from an acute
care setting. Performing independent hygienic care
in the hospital is a short-term goal. Long-term
goals are usually made for problem resolution after
discharge, especially from an acute care setting.
The nurse writes the following goal 4 "Client will have a 7 AM blood pressure reading
for a client who is hypertensive: less than 140/90" would be the most appropriate
"Client will maintain a blood pressure outcome criterion. It is clientcentered, singular,
within acceptable limits." Which of observable, measurable, time-limited, & realistic.
the following would be the most "Client will request pain medication as needed"
appropriate outcome criterion? does not allow the nurse to be able to determine if
1. "Client will request pain medication change has taken place. It would be more
as needed." measurable to state the client will rate pain below
2. "Client will experience no 4 on a scale of 0 to 10 by 24 hours. "Client will
headache or dizziness." experience no headache or dizziness" is not time-
3. "Client will identify at least two limited. "Client will identify at least two things that
things that cause stress." cause stress" is not time-limited or singular.
4. "Client will have a 7 AM blood
pressure reading less than 140/90."
, Nursing interventions may be 4 Preparing a client for a diagnostic test is an
categorized based upon the degree example of a physician-initiated intervention.
of nursing autonomy. Which of the Teaching a client to administer his or her insulin
following nursing interventions is injection is an example of a nurse-initiated
considered as physician- or intervention. Assisting a new mother with breast-
prescriber-initiated? feeding is an example of a nurse-initiated
1. Teaching a client to administer his intervention. Notifying a nutritionist of a client's
or her insulin injection dietary preferences is a collaborative intervention.
2. Assisting a new mother with
learning the art of breast-feeding
3. Notifying the nutritionist of a
client's specific dietary preferences
4. Administering a cleansing enema
in preparation for radiological testing
Nursing interventions should be 3 The intervention statement does not include how
documented according to specific frequently the warm soaks should be applied. The
criteria in order that they may be method is applying warm, wet soaks to the patient's
clearly understood by other leg while awake. The quantity is warm, wet soaks.
members of the nursing team. The The qualification of the person who will perform
intervention statement "Nurse will the action is the designation of "the nurse."
apply warm, wet soaks to the
patient's leg while awake" lacks
which of the following components?
1. Method
2. Quantity
3. Frequency
4. Performing staff
