Chapter 08: Planning

Chapter 08: Planning

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. The nurse is caring for a patient who has undergone abdominal surgery. The patient stated prior to surgery that “I don’t think I’ll be able to handle this if I get a colostomy. I wouldn’t know how to manage it.” There is no “next of kin” listed in the patient’s record. The patient is complaining of severe surgical pain. The nurse is correct when addressing which nursing diagnosis first?

ANS:  A

Use of Maslow’s hierarchy of needs helps to organize the most-urgent to less-urgent needs. This framework organizes patient data according to basic human needs common to all individuals. Maslow’s theory suggests that basic needs, such as physiologic needs, must be met before higher needs, such as self-esteem. The first level is “physiologic” and includes basic survival needs such as airway patency, breathing, circulation, oxygen level, nutrition, fluid intake, body temperature regulation, warmth, elimination, shelter, sexuality, infection, and pain level. The next level is “safety and security” includes physical safety (prevention of falls and drug side effects) and knowledge of routines and procedures. The level of “love and belonging” involves the need for love and affection, including compassion from the care provider, information from family and significant others, and strength of a support system. “Self-esteem” refers to the need to feel good about oneself and includes changes in body image (from injury, surgery, puberty) and changes in self-concept.

DIF:    Remembering                                 REF:   p. 107             OBJ:   8.2

TOP:   Planning

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination

2. Setting priorities among identified nursing diagnoses is the first step in the planning process. The nurse is responsible for:

ANS:  A

Setting priorities among identified nursing diagnoses is the first step in the planning process. The nurse is responsible for monitoring patient responses, making decisions culminating in a plan of care, and implementing interventions, including interdisciplinary collaboration and referral, as needed. The nurse is significantly accountable for achieving the desired outcomes.

DIF:    Remembering                                 REF:   p. 107             OBJ:   8.1

TOP:   Planning

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination

3. Which assessment made by the nurse should be addressed first?

ANS:  C

It is essential that the nurse identify life-threatening concerns and patient situations that need to be addressed most quickly. The ABCs of life support—airway, breathing, and circulation—are a valuable tool for directing the nurse’s thought process. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds. For instance, if a patient is in respiratory arrest, the most critical goal is for the patient to begin breathing. The reddened coccyx, decreased urinary output, and surgical incision drainage are not immediately life threatening.

DIF:    Understanding                                 REF:   p. 107             OBJ:   8.2

TOP:   Planning

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination

4. Which should the nurse address first?

ANS:  D

It is essential that the nurse identify life-threatening concerns and patient situations that need to be addressed most quickly. The ABCs of life support—airway, breathing, and circulation—are a valuable tool for directing the nurse’s thought process. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds. For instance, if a patient is in respiratory arrest, the most critical goal is for the patient to begin breathing. Pain, hunger, and decreased self-esteem are not immediately life threatening. The absence of pulse is.

DIF:    Understanding                                 REF:   p. 107             OBJ:   8.2

TOP:   Planning

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care

NOT:  Concepts: Care Coordination