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| ________, the fourth step of the nursing process, formally begins after the nurse develops a plan of care. With a care plan based on clear and relevant nursing diagnoses, the nurse initiates interventions that are most likely to achieve the goals and expected outcomes needed to support or improve the client's health status. |
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| a -_______ ______ is any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes |
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| lient outcomes. Ideally, the interventions a nurse uses are ____ ____ (see Chapter 5), providing the most current, up-to-date, and effective approaches for client problems. |
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| _____ _____ interventions are treatments performed through interactions with clients. For example, a client receives direct intervention in the form of medication administration, insertion of an intravenous infusion, or counseling during a time of grief |
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| _______ ______ interventions are treatments performed away from the client but on behalf of the client or group of clients |
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| . Both direct and indirect care measures fall under the intervention categories |
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| nurse-initiated, physician-initiated, and collaborative |
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| Each plan of care will be totally ___ to that client, with interventions individualized on the basis of the client's specific health problems |
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| A ____ _____ or protocol is a document that guides decisions and interventions for specific health care problems or conditions. |
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| a___ ___ is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific clients with identified clinical problems |
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| ___ to clients come from both illness and treatment. |
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| Nursing practice includes ____ ____ ___ , and ______ skills |
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| ognitive, interpersonal, and psychomotor (technical) skills |
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| _____ skills involve the application of critical thinking in the nursing process. To perform any intervention, always use good judgment and make sound clinical decisions |
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| ______ skills are essential for effective nursing action. The nurse develops a trusting relationship, expresses a level of caring, and communicates clearly with the client and family |
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| ______ skills require the integration of cognitive and motor activities. For example, when giving an injection you need to understand anatomy and pharmacology and use good coordination and precision to administer the injection correctly |
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| ___ ____ ____ are activities usually performed in the course of a normal day, including ambulation, eating, dressing, bathing, brushing the teeth, and grooming |
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| Activities of daily living (ADLs) |
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| such skills as shopping, preparing meals, writing checks, and taking medications are called what? |
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| Instrumental activities of daily living (IADLs) |
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| a direct care method that helps the client use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships. |
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| a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention. |
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| ____ _____ actions promote health and prevent illness to avoid the need for acute or rehabilitative health care. |
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| _____ care measures are actions that support the effectiveness of direct care interventions ( |
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| ___ ____ means that clients and families invest time in carrying out required treatments. |
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1. When does implementation begin as the fourth step of the nursing process?
1. During the assessment phase
2. Immediately, in some critical situations
3. After the care plan has been developed
4. After there is mutual goal setting between nurse and client |
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2. Mr. Switzer is a 34-year-old client who had a surgical repair of an abdominal hernia this morning. At 12 noon the nurse records Mr. Switzer's vital signs on the recovery room flow sheet. The recording of vital signs is an example of:
1. Psychomotor skill
2. Indirect care measure
3. Physical care technique
4. Anticipating complications |
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3. Before beginning insertion of a client's indwelling urinary catheter, the nurse considers the steps to take to avoid the possibility of breaking sterile technique, which could cause a urinary tract infection. This is an example of what type of decision making?
1. Identifying areas of assistance
2. Reviewing possible consequences of a nursing action
3. Reassessing the clinical situation to revise the care plan
4. Determining the probability of all consequences of the catheterization |
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4. Interdisciplinary care plans represent:
1. All nursing personnel having input in the care plan
2. Contributions of all disciplines caring for the client
3. The client's expressed wishes and advance directives
4. Physicians and nurses working together to develop a plan of care |
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5. Environmental factors heavily affect a client's care. Your first concern for the client includes which of the following?
1. Safety
2. Nurse staffing
3. Confidentiality
4. Adequate pain relief |
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6. In which of the following examples is a nurse applying critical thinking attitudes when performing a dressing change?
1. Following the procedural guideline for a dressing change
2. Seeking necessary knowledge on the steps of the procedure
3. Showing confidence in knowing which dressing materials to use
4. Being sure that the dressing covers the entire wound completely. |
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7. Which steps do you follow when you are asked to perform a procedure with which you are unfamiliar? (Choose all that apply.)
1. Seek necessary knowledge.
2. Reassess the client's condition.
3. Collect all equipment necessary.
4. Have an experienced nurse available to assist.
5. Consider all possible consequences of the procedure. |
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