Fundamentals Of Nursing NCLEX Quiz 19

1. For clients to participate in goal setting. they should be:

Alert and have some degree of independence.

Ambulatory and mobile.

Able to speak and write.

Able to read and write.

Clients need to be alert and have some degree of independence in order to participate in goal setting. Being alert ensures that they are fully aware of the goals being set and can actively engage in the process. Having some degree of independence allows them to make their own decisions and have control over their own goals. This independence enables them to take ownership of their goals and work towards achieving them.

Explanation

Clients need to be alert and have some degree of independence in order to participate in goal setting. Being alert ensures that they are fully aware of the goals being set and can actively engage in the process. Having some degree of independence allows them to make their own decisions and have control over their own goals. This independence enables them to take ownership of their goals and work towards achieving them.

2. Once a nurse assesses a client's condition and identifies appropriate nursing diagnoses. a:

Plan is developed for nursing care.

Physical assessment begins

List of priorities is determined.

Review of the assessment is conducted with other team members.

After assessing a client's condition and identifying appropriate nursing diagnoses, the next step is to develop a plan for nursing care. This involves creating a detailed outline of the interventions and actions that need to be implemented to address the client's needs and achieve desired outcomes. The plan will include specific goals, interventions, and evaluation criteria to guide the nursing care provided. This step is crucial in ensuring that the client receives appropriate and individualized care based on their specific needs and nursing diagnoses.

Explanation

After assessing a client's condition and identifying appropriate nursing diagnoses, the next step is to develop a plan for nursing care. This involves creating a detailed outline of the interventions and actions that need to be implemented to address the client's needs and achieve desired outcomes. The plan will include specific goals, interventions, and evaluation criteria to guide the nursing care provided. This step is crucial in ensuring that the client receives appropriate and individualized care based on their specific needs and nursing diagnoses.

3. Priorities are established to help the nurse anticipate and sequence nursing interventions when a client has multiple problems or alterations. Priorities are determined by the client's:

Physician

Non Emergent. non-life threatening needs

Future well-being.

Urgency of problems

Priorities in nursing care are determined by the urgency of the client's problems. This means that the nurse will prioritize interventions for the most urgent or life-threatening issues first. By addressing the urgent problems first, the nurse can ensure that the client's immediate needs are met and potentially prevent further complications. This approach helps in providing efficient and effective care to the client.

Explanation

Priorities in nursing care are determined by the urgency of the client's problems. This means that the nurse will prioritize interventions for the most urgent or life-threatening issues first. By addressing the urgent problems first, the nurse can ensure that the client's immediate needs are met and potentially prevent further complications. This approach helps in providing efficient and effective care to the client.

4. A client centered goal is a specific and measurable behavior or response that reflects a client's:

Desire for specific health care interventions

Highest possible level of wellness and independence in function.

Physician’s goal for the specific client.

Response when compared to another client with a like problem.

A client-centered goal refers to a specific and measurable behavior or response that reflects the client's highest possible level of wellness and independence in function. This means that the goal is focused on improving the client's overall well-being and ability to function independently. It takes into consideration the client's individual needs, preferences, and desired outcomes, rather than being influenced by healthcare interventions or comparisons to other clients.

Explanation

A client-centered goal refers to a specific and measurable behavior or response that reflects the client's highest possible level of wellness and independence in function. This means that the goal is focused on improving the client's overall well-being and ability to function independently. It takes into consideration the client's individual needs, preferences, and desired outcomes, rather than being influenced by healthcare interventions or comparisons to other clients.

5. The nurse writes an expected outcome statement in measurable terms. An example is:

Client will have less pain.

Client will be pain free.

Client will report pain acuity less than 4 on a scale of 0-10.

Client will take pain medication every 4 hours around the clock.

The nurse writes an expected outcome statement in measurable terms. This means that the outcome can be objectively measured or observed. Out of the given examples, "Client will report pain acuity less than 4 on a scale of 0-10" is the only statement that can be measured. The other statements, "Client will have less pain" and "Client will be pain-free," are subjective and cannot be quantified or measured accurately. Similarly, "Client will take pain medication every 4 hours around the clock" is an action that can be observed but does not provide a measurable outcome.

Explanation

The nurse writes an expected outcome statement in measurable terms. This means that the outcome can be objectively measured or observed. Out of the given examples, "Client will report pain acuity less than 4 on a scale of 0-10" is the only statement that can be measured. The other statements, "Client will have less pain" and "Client will be pain-free," are subjective and cannot be quantified or measured accurately. Similarly, "Client will take pain medication every 4 hours around the clock" is an action that can be observed but does not provide a measurable outcome.

6. As goals. outcomes. and interventions are developed. the nurse must:

Be in charge of all care and planning for the client.

Be aware of and committed to accepted standards of practice from nursing and other disciples.

Not change the plan of care for the client.

Be in control of all interventions for the client.

The nurse must be aware of and committed to accepted standards of practice from nursing and other disciplines because these standards provide guidelines and principles for providing safe and effective care to clients. By being aware of these standards, the nurse can ensure that their interventions and care align with best practices and evidence-based guidelines. This helps to promote positive outcomes for the client and ensures that the nurse is providing care that is in line with professional standards. It is not necessary for the nurse to be in charge of all care and planning for the client, be in control of all interventions, or not change the plan of care for the client in order to meet this requirement.

Explanation

The nurse must be aware of and committed to accepted standards of practice from nursing and other disciplines because these standards provide guidelines and principles for providing safe and effective care to clients. By being aware of these standards, the nurse can ensure that their interventions and care align with best practices and evidence-based guidelines. This helps to promote positive outcomes for the client and ensures that the nurse is providing care that is in line with professional standards. It is not necessary for the nurse to be in charge of all care and planning for the client, be in control of all interventions, or not change the plan of care for the client in order to meet this requirement.

7. To initiate an intervention the nurse must be competent in three areas. which include:

Knowledge. function. and specific skills

Experience. advanced education. and skills.

Skills. finances. and leadership.

Leadership. autonomy. and skills.

The correct answer is "Knowledge, function, and specific skills." This answer suggests that in order for a nurse to initiate an intervention, they must have the necessary knowledge, understanding of their role and responsibilities, and the specific skills required to carry out the intervention effectively. This implies that the nurse needs to have a solid foundation of theoretical knowledge, be able to apply that knowledge in practice, and possess the specific skills necessary for the intervention at hand.

Explanation

The correct answer is "Knowledge, function, and specific skills." This answer suggests that in order for a nurse to initiate an intervention, they must have the necessary knowledge, understanding of their role and responsibilities, and the specific skills required to carry out the intervention effectively. This implies that the nurse needs to have a solid foundation of theoretical knowledge, be able to apply that knowledge in practice, and possess the specific skills necessary for the intervention at hand.

8. Collaborative interventions are therapies that require:

Physician and nurse interventions.

Nurse and client interventions.

Client and Physician intervention.

Multiple health care professionals.

Collaborative interventions involve the participation of multiple healthcare professionals. This means that it requires the combined efforts and expertise of physicians, nurses, and other healthcare professionals to provide effective and comprehensive care to the client. By working together, these professionals can bring their unique skills and knowledge to the table, ensuring that the client receives the best possible care and treatment.

Explanation

Collaborative interventions involve the participation of multiple healthcare professionals. This means that it requires the combined efforts and expertise of physicians, nurses, and other healthcare professionals to provide effective and comprehensive care to the client. By working together, these professionals can bring their unique skills and knowledge to the table, ensuring that the client receives the best possible care and treatment.

9. Planning is a category of nursing behaviors in which:

The nurse determines the health care needed for the client.

The Physician determines the plan of care for the client.

Client-centered goals and expected outcomes are established.

The client determines the care needed.

In the category of nursing behaviors known as planning, the nurse is responsible for establishing client-centered goals and expected outcomes. This involves assessing the client's needs and preferences, collaborating with the client and other healthcare professionals, and developing a plan of care that is tailored to meet the client's specific goals and needs. The nurse takes into consideration the client's individual circumstances and works towards achieving the desired outcomes through effective interventions and strategies. This approach ensures that the care provided is focused on the client's unique needs and promotes their overall well-being.

Explanation

In the category of nursing behaviors known as planning, the nurse is responsible for establishing client-centered goals and expected outcomes. This involves assessing the client's needs and preferences, collaborating with the client and other healthcare professionals, and developing a plan of care that is tailored to meet the client's specific goals and needs. The nurse takes into consideration the client's individual circumstances and works towards achieving the desired outcomes through effective interventions and strategies. This approach ensures that the care provided is focused on the client's unique needs and promotes their overall well-being.

10. When establishing realistic goals. the nurse:

Bases the goals on the nurse’s personal knowledge.

Knows the resources of the health care facility. family. and the client.

Must have a client who is physically and emotionally stable.

Must have the client’s cooperation.

When establishing realistic goals, the nurse must have knowledge of the resources available in the healthcare facility, as well as the support from the client's family and the client themselves. This is important because the nurse needs to understand the limitations and possibilities of the resources at hand in order to set achievable goals. Additionally, involving the client's family and gaining their cooperation can greatly enhance the chances of success in reaching the goals.

Explanation

When establishing realistic goals, the nurse must have knowledge of the resources available in the healthcare facility, as well as the support from the client's family and the client themselves. This is important because the nurse needs to understand the limitations and possibilities of the resources at hand in order to set achievable goals. Additionally, involving the client's family and gaining their cooperation can greatly enhance the chances of success in reaching the goals.