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| ______ the third step of the nursing process, is a category of nursing behaviors in which a nurse sets client-centered goals and expected outcomes and plans nursing interventions. |
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| _____ ______ is the ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions (Hendry and Walker, 2004). In other words, as you care for a client or a group of clients, there are certain aspects of care that you need to deal with before others. |
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| _____ help you to anticipate and sequence nursing interventions when a client has multiple nursing diagnoses and collaborative problems |
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| In regard to importance, it helps to classify priorities as ___ ___ or ____ |
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| high, intermediate, or low |
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| _______ priorities are sometimes both physiological and psychological and may address other basic human needs |
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| _____ priority nursing diagnoses involve the nonemergent, non–life-threatening needs of the client. |
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| _____ -priority nursing diagnoses are not always directly related to a specific illness or prognosis but affect the client's future well-being. |
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| A ______ is an aim, intent, or end |
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| a ____ ____ goal is a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function |
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| Each goal is _____ _____ so that the health care team has a common time frame for problem resolution. |
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| a ___ ___ goal is an objective behavior or response that you expect a client to achieve in a short time, usually less than a week |
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| a ___ ____ goal is an objective behavior or response that you expect a client to achieve over a longer period, usually over several days, weeks, or months. |
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| A _____ ____ ___ _____ as an individual, family, or community state, behavior, or perception that is measurable along a continuum in response to a nursing intervention. |
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| nursing-sensitive client outcome |
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| There are seven guidelines for writing goals and expected outcomes. The guidelines are: |
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| client-centered, singular, observable, measurable, time-limited, mutual, and realistic. |
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| A ___ ____ ____ enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care. All nurses who care for a given client will then carry out these nursing interventions throughout a given day during a client's length of stay. |
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| a _____ rationale is the reason that you chose a specific nursing action, based on supporting evidence. |
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| _____ _____ are multidisciplinary treatment plans that outline the treatments or interventions clients need to have while they are in a health care setting for a specific disease or condition. |
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| _______ is a process in which you seek the expertise of a specialist, such as your nursing instructor, to identify ways to handle problems in client management or the planning and implementation of therapies. |
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1. Sheila is assigned to a client who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment Sheila anticipates the need to monitor the client's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. Sheila will have to establish priorities of care in which of the following situations? (Choose all that apply.)
1. The family comes to visit the client.
2. The client expresses concern about pain control.
3. The client's vital signs change, showing a drop in blood pressure.
4. The charge nurse approaches Sheila and requests a report at end of shift. |
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2. Sheila's client signals with her call light. Sheila enters the room and finds the drainage tube disconnected, the IV has 100 ml of fluid remaining, and the client has asked to be turned. Which of the following should Sheila perform first?
1. Reconnect the drainage tubing.
2. Inspect the condition of the IV dressing.
3. Improve client's comfort, and turn to her side.
4. Go to the medication room, and obtain the next IV fluid bag. |
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3. In her nursing care plan, Sheila enters expected outcomes for her client. Which of the following expected outcomes are written correctly? (Choose all that apply.)
1. Client will remain afebrile until discharge.
2. IV site will be without phlebitis by the third postoperative day.
3. Provide incentive spirometer for deep breathing every 2 hours.
4. Client will report pain and turn more freely by the first postoperative day. |
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4. Sheila set a time limit for her outcomes. The time frame serves to:
1. Indicate which outcome has priority
2. Indicate the time it takes to complete an intervention
3. Indicate how long Sheila is scheduled to care for the client
4. Indicate when the client is expected to respond in the desired manner |
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5. A client-centered goal is a specific and measurable behavior or response that reflects a:
1. Physician's goal for the specific client
2. Client's desire for specified health care interventions
3. Client's response when compared to another client with a like problem
4. Client's highest possible level of wellness and independence in function |
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6. The nurse writes an expected outcome statement in measurable terms. An example is:
1. Client will be pain free.
2. Client will have less pain.
3. Client will take pain medication every 4 hours.
4. Client will report pain acuity less than 4 on a scale of 0 to 10. |
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7. Sheila's client is experiencing nausea and abdominal distention postoperatively. Sheila initiates the interventions listed below. Which of the interventions are examples of independent interventions? (Choose all that apply.)
1. Provide frequent mouth care.
2. Maintain IV infusion at 100 mL/hr.
3. Administer Compazine via rectal suppository.
4. Consult with dietitian on initial foods to offer client.
5. Control aversive odors or unpleasant visual stimulation that trigger nausea. |
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8. Collaborative interventions are therapies that require:
1. Nurse and client intervention
2. Physician and nurse intervention
3. Client and physician intervention
4. Multiple health care professionals |
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