CHAPTER 8: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 8: Planning Multiple Choice Questions 1. The nurse is caring for a postoperative abdominal surgery patient who expressed pre-surgery concerns about managing a colostomy and is now complaining of severe pain. Which nursing diagnosis should the nurse prioritize first? A. Pain B. Alteration in body image C. Knowledge deficit D. Risk for falls Answer: A Explanation: According to Maslow's hierarchy, physiological needs like pain take precedence over psychosocial concerns. Pain management is urgent to improve patient comfort and facilitate recovery, while other diagnoses (e.g., body image or knowledge deficit) are secondary. Why Other Options Are Wrong: B is incorrect because body image concerns, while important, are less urgent than acute pain. C is incorrect as education can occur after pain relief. D is incorrect because fall risk becomes relevant only after administering pain medication. 2. Which action is essential when setting priorities among identified nursing diagnoses during the planning phase? A. Monitoring patient responses B. Carrying out the provider’s plan of care C. Providing all interventions simultaneously D. Collaborating with other disciplines Answer: A Explanation: Prioritization requires ongoing assessment of patient responses to adjust care plans effectively. Monitoring ensures interventions align with evolving patient needs and outcomes. Why Other Options Are Wrong: B is incorrect because nursing prioritization is independent of provider orders. C is incorrect as interventions must be sequenced by urgency. D is incorrect because collaboration supports but does not replace prioritization. 3. Which assessment finding should the nurse address first for a postoperative patient? A. Reddened area on the coccyx B. Decreased urinary output C. Shortness of breath D. Drainage from the surgical incision Answer: C Explanation: Airway and breathing (ABCs) are immediate priorities. Shortness of breath may indicate life-threatening complications like pulmonary embolism or pneumonia. Why Other Options Are Wrong: A is incorrect because skin redness, while concerning, is not urgent. B is incorrect as decreased output requires monitoring but is less critical. D is incorrect because incision drainage is expected unless signs of infection arise. 4. Which patient issue requires immediate intervention by the nurse? A. Pain B. Hunger C. Decreased self-esteem D. Absence of pulse Answer: D Explanation: Absence of pulse indicates cardiac arrest, necessitating immediate CPR. Circulation is a top priority under the ABCs framework. Why Other Options Are Wrong: A, B, and C are incorrect because pain, hunger, and self-esteem, while important, are not life-threatening. 5. Which statement by the nurse reflects understanding of the planning phase in the nursing process? A. "Patients should be included in the planning process." B. "Families should not interfere in planning." C. "Planning focuses only on short-term goals." D. "Planning is the first phase of the nursing process." Answer: A Explanation: Patient involvement ensures goals are realistic and fosters cooperation. Planning is the third phase (after assessment and diagnosis) and includes both short- and long-term goals. Why Other Options Are Wrong: B is incorrect because family input can enhance care. C is incorrect as planning addresses both short- and long-term goals. D is incorrect because assessment precedes planning. 6. Which characteristic is essential for effective patient goals? A. Achievable within a month to be considered short-term B. Always labeled as "short-term" or "long-term" C. Mutually acceptable to the nurse, patient, and family D. Vague to allow flexibility in evaluation Answer: C Explanation: Mutual agreement ensures goals align with patient values and capabilities, improving adherence and outcomes. Goals should also be specific and measurable. Why Other Options Are Wrong: A is incorrect because short-term goals are typically achievable within days to a week. B is incorrect as time labels are not mandatory. D is incorrect because vague goals hinder evaluation. 7. When creating goals for a nursing care plan, which concept should the nurse prioritize? A. Developing goals with the patient and family B. Setting goals based solely on nurse preferences C. Including detailed actions within the goal statement D. Establishing aggressive goals to ensure success Answer: A Explanation: Collaborative goal-setting empowers patients and enhances compliance. Goals should be patient-centered, realistic, and separate from interventions. Why Other Options Are Wrong: B is incorrect because nurse-imposed goals may lack patient buy-in. C is incorrect as actions are part of interventions, not goals. D is incorrect because unrealistic goals demotivate patients. 8. Which statement about diversity considerations in care planning is accurate? A. Men generally struggle less with health care terminology. B. Minority populations often face challenges with health literacy. C. Older adults easily understand health teachings due to experience. D. Disabilities do not affect goal development. Answer: B Explanation: Socioeconomic and language barriers often reduce health literacy in minority groups. Tailored teaching strategies are essential for equitable care. Why Other Options Are Wrong: A is incorrect because gender does not determine health literacy. C is incorrect as aging may impair comprehension. D is incorrect because disabilities require individualized accommodations. 9. Which example correctly represents a short-term goal? A. "The patient will lose 50 lb in 1 year." B. "The patient will ambulate 1 mile without shortness of breath." C. "The patient will change the colostomy bag independently in 6 weeks." D. "The patient will eat 75% of meals for the next three days." Answer: D Explanation: Short-term goals are achievable within days to a week. Eating 75% of meals in three days is specific, measurable, and time-bound. Why Other Options Are Wrong: A and C are incorrect because they describe long-term goals. B is incorrect as it lacks a timeframe. 10. For the nursing diagnosis activity intolerance related to oxygen imbalance, which goal is correctly written? A. "The patient will walk 1 mile without shortness of breath." B. "The patient will ambulate 100 feet without shortness of breath on postoperative day 3." C. "The patient will climb stairs without shortness of breath by day 2." D. "The patient will tolerate activity." Answer: B Explanation: The goal is specific (100 feet), measurable (no shortness of breath), and time-bound (postoperative day 3), aligning with the diagnosis. Why Other Options Are Wrong: A is incorrect due to missing timeframe. C is incorrect because stair quantity is unspecified. D is incorrect as it is vague and unmeasurable. 11. Which factor is a barrier to achieving patient goals? A. Effects of pain or depression B. Patient involvement in goal-setting C. Family participation in planning D. Realistic patient expectations Answer: A Explanation: Pain and depression reduce motivation and cooperation, hindering goal attainment. Addressing these issues is crucial first. Why Other Options Are Wrong: B and C are incorrect because involvement improves adherence. D is incorrect as realistic expectations support success. 12. For a postoperative patient with a fever, which statement is a patient-centered goal? A. "The patient’s temperature will normalize within 24 hours." B. "The nurse will administer antipyretics every 4 hours." C. "Skin integrity will be maintained until ambulation." D. "The patient will ambulate 10 feet by postoperative day 2." Answer: D Explanation: Patient-centered goals focus on actions the patient will perform (e.g., ambulating). The other options describe nurse actions or outcomes. Why Other Options Are Wrong: A and C are incorrect because they describe outcomes, not patient actions. B is incorrect as it focuses on nursing interventions. 13. Which goal is an example of a measurable outcome? A. "The patient will lift 10 lb by week one." B. "The patient will lift weights by week’s end." C. "The patient will lift normal weight amounts." D. "The patient will lift an acceptable weight by week one." Answer: A Explanation: Measurable goals include specific criteria (e.g., "10 lb") and timeframes ("week one"). Why Other Options Are Wrong: B, C, and D are incorrect because they lack specificity (e.g., "weights," "normal," "acceptable"). 14. When should the nurse evaluate a patient’s progress toward goals? A. At the end of every shift B. At least every 24 hours C. Based on intervention and patient condition D. Only at discharge Answer: C Explanation: Evaluation frequency depends on the intervention’s urgency and the patient’s condition (e.g., daily for acute issues, weekly for chronic care). Why Other Options Are Wrong: A and B are incorrect because rigid schedules may not suit all goals. D is incorrect as ongoing evaluation is essential. 15. How should standardized care plans be utilized? A. Individualized for each patient B. Implemented without modification C. Replacing nurse judgment D. Excluding nursing diagnoses Answer: A Explanation: Standardized plans provide a foundation but must be tailored to meet individual patient needs and preferences. Why Other Options Are Wrong: B is incorrect because customization is essential. C is incorrect as nurses must critically apply plans. D is incorrect because nursing diagnoses guide care planning. 16. Which term describes nursing interventions based on provider orders? A. Dependent B. Independent C. Collaborative D. Nursing Interventions Classification (NIC) Answer: A Explanation: Dependent interventions (e.g., medication administration) derive from provider orders, unlike independent or collaborative actions. Why Other Options Are Wrong: B is incorrect because independent interventions are nurse initiated. C is incorrect as collaboration involves teamwork. D is incorrect because NIC is a standardized taxonomy, not an intervention type. 17. What type of intervention is medication administration? A. Independent B. Dependent C. Collaborative D. Interdisciplinary Answer: B Explanation: Medication administration requires a provider’s order, making it a dependent intervention. Why Other Options Are Wrong: A is incorrect because nurses cannot independently prescribe. C and D are incorrect as medication administration typically does not require team coordination. 18. Which action is a dependent nursing intervention? A. Using heel protectors B. Providing preadmission teaching C. Performing medication reconciliation D. Administering oxygen via mask Answer: D Explanation: Oxygen administration requires a provider’s order, classifying it as dependent. Other options are nurse-initiated (A, B) or collaborative (C). Why Other Options Are Wrong: A and B are incorrect because they are independent interventions. C is incorrect as reconciliation often involves pharmacy collaboration. 19. Physical therapy and home health care are examples of which intervention type? A. Collaborative B. Dependent C. Independent D. Assessment Answer: A Explanation: Collaborative interventions involve teamwork with other disciplines (e.g., PT, home health) to achieve patient goals. Why Other Options Are Wrong: B is incorrect because dependent interventions rely on provider orders. C is incorrect as independent actions are nurse-driven. D is incorrect because assessment is a separate nursing process step. 20. When should discharge planning begin for a hospitalized patient? A. The day before discharge B. Upon admission C. Prior to admission D. On discharge day Answer: B Explanation: Discharge planning starts at admission to ensure continuity of care and address post-hospital needs early. Why Other Options Are Wrong: A, C, and D are incorrect because delaying planning risks gaps in care coordination. 21. Which statement about discharge planning is accurate? A. "It reduces hospital readmissions." B. "It increases complications." C. "It adapts only if the patient’s condition worsens." D. "It begins after discharge." Answer: A Explanation: Effective discharge planning lowers readmission rates by addressing post-hospital needs (e.g., follow-up care, education). Why Other Options Are Wrong: B is incorrect because planning reduces complications. C is incorrect as planning adapts to all condition changes. D is incorrect because planning starts at admission. MULTIPLE RESPONSE QUESTIONS 1. Which responsibilities are critical during the planning phase of the nursing process? (Select all that apply.) A. Prioritizing patient needs B. Developing mutually agreed-on goals C. Determining outcome criteria D. Identifying interventions E. Implementing the care plan Answer: A, B, C, D Explanation: Planning involves prioritizing needs, setting goals, defining outcomes, and selecting interventions. Implementation occurs in the next phase. Why Other Options Are Wrong: E is incorrect because implementation follows planning. 2. Which actions should the nurse complete during the planning phase? (Select all that apply.) A. Prioritize nursing diagnoses B. Set short- and long-term goals C. Identify outcome indicators D. List nursing interventions E. Gather assessment data Answer: A, B, C, D Explanation: Planning includes prioritizing diagnoses, goal-setting, outcome identification, and intervention selection. Assessment data gathering occurs earlier. Why Other Options Are Wrong: E is incorrect because assessment precedes planning. 3. How does patient involvement in care planning improve outcomes? (Select all that apply.) A. Increases awareness of needs B. Accepts non-measurable goals C. Encourages commitment to goals D. Enhances empowerment E. Ensures all goals are unrealistic Answer: A, C, D Explanation: Involvement fosters awareness, goal ownership, and empowerment, improving adherence. Goals must be measurable and realistic. Why Other Options Are Wrong: B is incorrect because goals should be measurable. E is incorrect as unrealistic goals hinder progress. 4. Which characteristics define a measurable goal? (Select all that apply.) A. Specific B. Concrete C. Vague D. Easy to evaluate E. Nonspecific Answer: A, B, D Explanation: Measurable goals are specific (e.g., "walk 50 feet"), concrete, and evaluable (e.g., "within 3 days"). Why Other Options Are Wrong: C and E are incorrect because vague or nonspecific goals cannot be measured.