Chapter 018

Potter & Perry: Fundamentals of Nursing, 7th Edition
Test Bank
Chapter 18: Planning Nursing Care
MULTIPLE CHOICE
1. The nurse is working with a client who is being prepared for a diagnostic test this
afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of
the following is the most appropriate label with regard to prioritizing her request?
1. Low priority
2. An unmet need
3. Intermediate priority
4. A safety and security need
ANS: 1
The clients request would be of low priority because it is not directly related to a specific
illness or prognosis. An unmet need is not the most appropriate label for the clients
request. The clients request is not an intermediate priority. An intermediate priority is
one that involves the non-emergent, nonlife-threatening needs of the client. The clients
request is not a safety and security need; the outcome does not threaten her well-being.
DIF: A
REF: 262
OBJ: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX test plan designation: Health Promotion and Maintenance
2. Assuming that all of the following are realistic, a long-term goal for a client that is a
tailor by trade and has been admitted for eye surgery should include:
1. Returning to sewing
2. Preventing ocular infection
3. Administering eye drops on time in the hospital
4. Performing independent hygienic care in the hospital
ANS: 1
Long-term goals focus on prevention, rehabilitation, discharge, and health education. An
appropriate long-term goal for this client would be for rehabilitation and the clients
return to occupation, in this case sewing. Preventing ocular infection is a short-term goal.
A short-term goal is expected to be achieved within a short time, usually in less than 1
week. In 1 weeks time, the clients risk for infection should be greatly reduced.
Administering eye drops on time in the hospital is a short-term goal. Long-term goals are
usually designed for problem resolution after discharge, especially from an acute care
setting. Performing independent hygienic care in the hospital is a short-term goal. Longterm goals are usually made for problem resolution after discharge, especially from an
acute care setting.
DIF: A
REF: 265
OBJ: Knowledge
Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
18-2
3. The nurse writes the following goal for a client who is hypertensive: Client will
maintain a blood pressure within acceptable limits. Which of the following would be the
most appropriate outcome criterion?
1. Client will request pain medication as needed.
2. Client will experience no headache or dizziness.
3. Client will identify at least two things that cause stress.
4. Client will have a 7 AM blood pressure reading less than 140/90.
ANS: 4
Client will have a 7 AM blood pressure reading less than 140/90 would be the most
appropriate outcome criterion. It is client-centered, singular, observable, measurable,
time-limited, and realistic. Client will request pain medication as needed does not allow
the nurse to be able to determine if change has taken place. It would be more measurable
to state the client will rate pain below 4 on a scale of 0 to 10 by 24 hours. Client will
experience no headache or dizziness is not time-limited. Client will identify at least two
things that cause stress is not time-limited or singular.
DIF: A
REF: 266
OBJ: Comprehension
4. Nursing interventions may be categorized based upon the degree of nursing autonomy.
Which of the following nursing interventions is considered as physician- or prescriberinitiated?
1. Teaching a client to administer his or her insulin injection
2. Assisting a new mother with learning the art of breast-feeding
3. Notifying the nutritionist of a clients specific dietary preferences
4. Administering a cleansing enema in preparation for radiological testing
ANS: 4
Preparing a client for a diagnostic test is an example of a physician-initiated intervention.
Teaching a client to administer his or her insulin injection is an example of a nurseinitiated intervention. Assisting a new mother with breast-feeding is an example of a
nurse-initiated intervention. Notifying a nutritionist of a clients dietary preferences is a
collaborative intervention.
DIF: A
REF: 268
OBJ: Comprehension
5. Nursing interventions should be documented according to specific criteria in order that
they may be clearly understood by other members of the nursing team. The intervention
statement Nurse will apply warm, wet soaks to the patients leg while awake lacks
which of the following components?
1. Method
2. Quantity
Test Bank
18-3
3. Frequency
4. Performing staff
ANS: 3
The intervention statement does not include how frequently the warm soaks should be
applied. The method is applying warm, wet soaks to the patients leg while awake. The
quantity is warm, wet soaks. The qualification of the person who will perform the action
is the designation of the nurse.
DIF: A
REF: 273
OBJ: Knowledge
6. In order that they are clear and easily understood by other members of the health care
team, the nurse recognizes that client goals or outcomes should be documented according
to specific criterion. Of the following, the outcome statement that best meets the
established criteria is:
1. Client will describe activity restrictions.
2. Client will verbalize understanding of treatments.
3. Client will be ambulated in hallway 3 times each day.
4. Clients respiratory rate will remain within 20 to 24 breaths per minute by 9/24.
ANS: 4
Clients respiratory rate will remain within 20 to 24 breaths per minute by 9/24 is a
correctly written outcome statement. It is client-centered, singular, observable,
measurable, time-limited, and realistic. Client will describe activity restrictions is not
time-limited. Client will verbalize understanding of treatments is not observable or
time-limited. The client will state the purpose of the breathing treatments by 4/10
would be more appropriate. Client will be ambulated in hallway 3 times each day is not
client-centered. A correct outcome statement would be Client will ambulate in the hall 3
times a day.
DIF: A
REF: 267
OBJ: Comprehension
7. The client is receiving postural drainage from physical therapy and intermittent breathing
treatments from respiratory therapy. Which type of care plan would be the ideal method
to document interventions for this client?
1. Nursing Kardex
2. Computerized care plan
3. Critical pathway
4. Standardized care plan
ANS: 3
Test Bank
18-4
Critical pathways allow staff from all disciplines to develop integrated care plans for a
projected length of stay or number of visits for clients with a specific case type. The
nursing Kardex is a card-filing system that allows quick reference to the particular needs
of the client for certain aspects of nursing care. A computerized care plan is a
standardized care plan on the computer. A standardized care plan is a prewritten plan
created for a specific nursing diagnosis or clinical problem. The nurse individualizes the
care plan for the clients needs.
DIF: A
REF: 274
OBJ: Knowledge
8. The nurse is involved in requesting a management consultation for personnel-related
issues. Which of the following is true regarding the consultation process in which the
nurse is involved?
1. The problem area should be totally delegated to the consultant.
2. Consultation is often used when the exact problem remains unclear.
3. The problem area is identified by any member of the health care team.
4. Feelings about the problem should be described to the consultant by the nurse.
ANS: 2
Consultation is appropriate when the nurse has identified a problem that cannot be solved
using personal knowledge, skills, and resources, or when the exact problem remains
unclear. A consultant objectively entering a situation can more clearly assess and identify
the exact nature of the problem. The whole problem is not turned over to the consultant.
The consultant is not there to take over the problem but is there to assist the nurse in
resolving it. The person requesting the consult usually identifies the problem area. The
nurse should not bias the consultant with subjective and emotional conclusions about the
client and problem.
DIF: A
REF: 276
OBJ: Comprehension
9. In completing an assessment on an assigned client, the nurse obtains important
information for planning nursing care. Which of the following client needs should take
priority?
1. Difficulty breathing
2. Financial problems
3. A nutritional deficit
4. An impending divorce
ANS: 1
Test Bank
18-5
Difficulty breathing would be the highest priority client need. In general, priorities that
protect clients basic needs of safety, adequate oxygenation, and comfort are considered
high priority. Financial problems are a low-priority client need. Financial problems are
not directly related to a specific illness or prognosis but may affect the clients future
well-being. A nutritional deficit is an intermediate priority client need. It involves a non
life-threatening need of the client. An impending divorce is a low-priority client need. It
is a need that is not directly related to a specific illness or prognosis but may affect the
clients future well-being.
DIF: C
REF: 262
OBJ: Analysis
10. The nurse recognizes that client goals or outcomes should be documented according to
specific criterion in order that they are clear and easily understood by other members of
the health care team. Of the following, the outcome statement that best meets the
established criteria is the following:
1. Vital signs will return to within normal levels for a middle aged adult.
2. Nursing assistant will ambulate the client in the hallway 3 times each day.
3. Lungs will be clear to auscultation and respiratory rate will be 20/minute.
4. Output will be at least 100 mL/hour of clear yellow urine within 24 hours.
ANS: 4
Output will be at least 100 mL/hour of clear yellow urine within 24 hours. is clientcentered, singular, observable, measurable, time-limited, and realistic. Vital signs will
return to within normal levels for a middle aged adult. is not measurable (i.e., guidelines
for normal are not stated), and it is not time-limited (e.g., by when?). Nursing assistant
will ambulate the client in the hallway 3 times each day. is not client-centered. Lungs
will be clear to auscultation and respiratory rate will be 20/minute. is not singular and it
is not time-limited.
DIF: C
REF: 267
OBJ: Analysis
11. In goal setting, the nurse is aware that the factor that is associated with available client
resources and motivation is:
1. Realistic
2. Observable
3. Measurable
4. Client-centered
ANS: 1
Test Bank
18-6
The nurse sets realistic goals that can be achieved. This increases the clients motivation.
The nurse also takes available resources into consideration in order to set realistic goals.
Being observable means the nurse must be able to determine through observation if
change has taken place. Being measurable means the goal is written so the nurse has a
standard against which to measure the clients response to nursing care. Being clientcentered means the goal should reflect the clients behavior and responses expected as a
result of nursing interventions.
DIF: A
REF: 267
OBJ: Knowledge
An example of a nurse-initiated intervention is:
1. Providing client teaching
2. Administering medication
3. Ordering a liver CAT scan
4. Referring a client to physical therapy
ANS: 1
Health teaching is an example of a nurse-initiated intervention. Administering medication
is a physician-initiated intervention. Ordering a CAT scan is a physician-initiated
intervention. Referring a client to physical therapy is a collaborative intervention.
DIF: A
REF: 267-268
OBJ: Comprehension
Which of the following nursing interventions is considered as physician- or prescriberinitiated?
1. Taking vital signs
2. Providing support to a family
3. Changing a dressing 2 times each day
4. Measuring intake and output each shift
ANS: 3
Changing a dressing is a physician- or prescriber-initiated intervention. Taking vital signs
is a nurse-initiated intervention. Providing support to a family is a nurse-initiated
intervention. Measuring intake and output is a nurse-initiated intervention.
DIF: A
REF: 268
OBJ: Comprehension
14. Which one of the following interventions selected by the nurse is classified as Level 2,
Domain 2 (Physiological: complex)?
Test Bank
1.
2.
3.
4.
18-7
Maintaining regular bowel elimination

Promoting the health of the entire family
Managing severely restricted body movement
Restoring tissue integrity to areas damaged by friction
ANS: 4
Interventions to maintain or restore tissue integrity are classified as Level 2, Domain 2
(Physiological: Complex). Maintaining regular bowel elimination is classified as Level 2,
Domain 1 (Physiological: Basic). Promoting the health of the family is classified as Level
2, Domain 5 (Family). Managing restricted body movement is classified as Level 2,
Domain 1 (Physiological: Basic).
DIF: A
REF: 270
OBJ: Comprehension
15. In documentation of nursing care plans, critical pathways differ from traditional nursing
care plans in their:
1. Client outcomes
2. Client assessment
3. Nursing interventions
4. Multidisciplinary approach
ANS: 4
Critical pathways are multidisciplinary. They allow staff from all disciplines, such as
medicine, nursing, pharmacy, and social work, to develop integrated care plans for a
projected length of stay or number of visits for clients with a specific case type. Client
outcomes are included in both critical pathways and traditional nursing care plans. Client
assessment is necessary for developing and evaluating critical pathways and traditional
nursing care plans. Nursing interventions are included in critical pathways and in the
traditional nursing care plan.
DIF: A
REF: 274
OBJ: Comprehension
they may be clearly understood by other members of the nursing team. The most
appropriate of the following intervention statements is:
1. Offer fluids to the client q2h
2. Observe the clients respirations
3. Change the clients dressing daily
4. Irrigate the nasogastric tube q2h with 30 ml normal saline
ANS: 4
Test Bank
18-8
Irrigate the nasogastric tube q2h with 30 ml normal saline is the most appropriate
intervention statement. It includes the action, frequency, quantity, and method. Offer
fluids to the client q2h lacks the component of quantity. Observe the clients respirations
fails to indicate the frequency or method. Also, what is the reason for observation of the
clients respirations? Change the clients dressing daily omits the method.
DIF: C
REF: 267
OBJ: Analysis
they may be clearly understood by other members of the nursing team. The most
appropriate of the following intervention statements is the following:
1. Take vital signs.
2. Refer client to a therapist.
3. Turn client as needed while in bed.
4. Apply two 4 4 dry gauze dressing pads tid.
ANS: 4
Apply two 4 4 dry gauze dressing pads tid. is the most appropriate. It identifies the
action, frequency, quantity, and method. Take vital signs. fails to indicate the frequency
and fails to completely indicate nursing actions (e.g., what parameters are used to notify
the physician). Refer client to a therapist. fails to completely indicate nursing
interventions (e.g., what type of therapist). Turn client as needed while in bed. fails to
state an accurate frequency or precisely indicate the nursing actions.
DIF: A
REF: 267
OBJ: Comprehension
18. Care plans created by nursing students usually differ from those that are completed by
nurses working on client units. An aspect of the plan that is usually included in the
students care plan but not in the clients record is:
1. Client outcomes
2. Nursing diagnoses
3. Scientific rationales
4. Nursing interventions
ANS: 3
An aspect of a nursing care plan that is usually included in the students care plan, but not
in the clients record, is scientific rationales. Client outcomes are included in both student
care plans and the clients record. Nursing diagnoses are included in both student care
plans and the clients record. Nursing interventions are a component of both student care
plans and a nursing care plan in the clients record.
DIF: A
REF: 271
OBJ: Knowledge
Test Bank
18-9

19. The purpose and distinction of a concept map, which a nurse may use when
implementing a plan of care, are for:
1. Multidisciplinary communication
2. Quality assurance in the health care facility
3. Provision of a standardized format for client problems
4. Identification of the relationship of client problems and interventions
ANS: 4
A concept map is a diagram of client problems and interventions that shows their
relationship to one another. Multidisciplinary communication is enhanced with the use of
critical pathways, not concept maps. The use of a concept map promotes critical thinking
and helps nurses to organize complex client data, process complex relationships, and
achieve a holistic view of the clients situation. The purpose is not quality assurance in
the health care facility. Standardized or computerized care plans provide a standardized
format for client problems, not the concept map. A concept map is highly individualized.
DIF: A
REF: 274
OBJ: Comprehension
20. A client is newly diagnosed with diabetes mellitus. The nurse identifies a nursing
diagnosis of knowledge deficient related to new diagnosis and treatment needs. The most
appropriate outcome statement based upon the established criteria is the following:
1. Client will perform glucose measurements often.
2. Client will appear less anxious regarding diagnosis.
3. Urinary output will reach normal young adult levels.
4. Client will independently perform subcutaneous insulin injection by 8/31.
ANS: 4
Client will independently perform subcutaneous insulin injection by 8/31. is the most
appropriate outcome statement. It addresses the nursing diagnosis by identifying a
singular outcome the client can realistically achieve, is observable, and provides a time
frame. Client will perform glucose measurements often. does not specify a time frame.
Client will appear less anxious regarding diagnosis. is not an appropriate outcome
statement. There is no specific behavior observable for will appear. Urinary output
will reach normal young adult levels. is not an appropriate outcome statement. It does
not provide a standard against which to measure the clients response to nursing care, and
therefore is not measurable. It is also not time-limited.
DIF: A
REF: 267
OBJ: Comprehension
21. Which of the following is the best example of an intermediate prioritized client need for a
client diagnosed with risk of injury related to poor skin integrity?
Test Bank
1.
2.
3.
4.
18-10
Applying adequate clothing to ensure the clients warmth

Providing sufficient quantities of an aloe-based skin lotion
Helping the client select her favorite foods from the menu form
Dressing the clients feet in non-skid soled slippers when ambulating
ANS: 2
An intermediate priority is one that involves the non-emergent, nonlife-threatening
needs of the client. Having sufficient aloe-based lotion is required for maintaining good
skin integrity but is not required for meeting a life-threatening need. Although the other
options are an intermediate need, they are not the best option because they are not
directly related to the clients stated nursing diagnosis.
DIF: C
REF: 262
OBJ: Analysis
22. Which of the following would be the best example of a short-term safety goal for a client
who recently experienced abdominal surgery?
1. The client will show no systemic or local signs of infection by time of discharge
from hospital.
2. The client will demonstrate an understanding of the proper use of patient-controlled
analgesia (PCA).
3. The client will demonstrate effective coughing and deep-breathing techniques
within 2 hours of surgery.
4. The client will consistently use the call bell to notify the staff of a need for
assistance to the bathroom upon return to the nursing unit.
ANS: 4
Although all the options represent short-term goals, this option (consistently use the call
bell to notify the staff) is directly related to client safety because it deals with fall
prevention. Although this is short-term goal (by time of discharge), it is not as directly
related to safety as some other options. Although this is short-term goal (time is inferred
by nature of pain needs), it is not as directly related to safety as some other options.
Although this is short-term goal (2 hours), it is not as directly related to safety as some
other options.
DIF: C
REF: 265
OBJ: Analysis
23. Which of the following would be the most appropriate outcome criterion for the goal,
Clients pain will be managed to within an acceptable level within 30 minutes of
receiving pain medication.
1. Client will deny presence of any pain or discomfort.
2. Client will rate pain at a level of 3 or less out of a possible 10.
3. Client will demonstrate ability to request pain medication as needed.
4. Client will identify two external factors that decrease presence of pain.
Test Bank
18-11
ANS: 2
Client will rate pain at a level of 3 or less out of a possible 10 would be the most
appropriate outcome criterion because it is directly related to the management of pain
levels as reflected by the pain scale. Client will deny presence of any pain or discomfort
does not necessarily reflect a reasonable goal. Although client will demonstrate ability to
request pain medication as needed is directed towards pain management, it does not have
the primary focus that evaluating the pain management intervention has. Client will
identify two external factors that decrease presence of pain is not the best option because
it does not directly relate to pain management but the identification of contributing
factors.
DIF: C
REF: 266
OBJ: Analysis
24. The nurse is caring for a newly admitted client who is scheduled for diagnostic testing in
the morning. Which of the following client needs should take priority?
1. Inventory of clothes and other personal belongings
2. Orientation to the nursing unit and individual room
3. Interview regarding medications currently being taken
4. Assessment of body systems for presurgery checklist
ANS: 2
The clients admission has no acute physical needs and so the emotional need of
familiarization with the environment has priority. Inventory of clothes and other personal
belongings does not reflect a priority because it does not relate directly to a physical
need, and there are other emotional needs of higher priority. Interview regarding
medications currently being taken does not reflect a priority because it does not relate
directly to a physical need, and there are emotional needs of higher priority. Although
assessment of body systems for presurgery checklist reflects a needed nursing action, it is
not a priority because it does not relate directly to physical need, and there are other
emotional needs of higher priority.
DIF: C
REF: 262
OBJ: Analysis
25. Which of the following outcomes, made by a nurse planning care for a client recently
fitted with a hearing aid, best reflects an understanding of short-term client education
goals?
1. Client will properly clean the hearing aid ear piece daily with soap and water.
2. Client will state 3 positive effects of wearing his hearing aid at follow-up
appointment.
3. Client will wear hearing aid while awake to help improve his ability to understand
instructions.
4. Client will demonstrate ability to change the batteries in his hearing aid before
leaving clinic today.
Test Bank
18-12
ANS: 4
Although all the options represent short-term goals, client will demonstrate ability to
change the batteries in his hearing aid before leaving clinic today is directly related to
patient education because it relates to the proper care of the hearing aid. Client will
properly clean the hearing aid ear piece daily with soap and water does not directly relate
to client education but more to an expected client action. The goal does not include a time
limit for compliance. Although client will state 3 positive effects of wearing his hearing
aid at follow-up appointment may be a short-term goal (depends on time of next
appointment), it is not as directly related to client education as it is compliance-oriented.
Although client will wear hearing aid while awake to help improve his ability to
understand instructions may be a short-term goal, although there is no time limit, it is not
as related to client education as some other options.
DIF: C
REF: 262-263
OBJ: Analysis
26. Which of the following statements made by a new nursing graduate best reflects an
understanding of expected outcomes?
1. It gives the client something positive to strive towards.
2. They are statements of how the clients behavior should change.
3. They are measurable criteria by which I can evaluation whether a goal has been
achieved.
4. They provide the client with suggestions on how to achieve their long and short
term goals.
ANS: 3
They are measurable criteria by which I can evaluation whether a goal has been
achieved. It is necessary to use expected outcomes or measurable criteria to evaluate
goal achievement. Although outcomes are directed at times toward the alteration of client
behavior, They are statements of how the clients behavior should change. is not the
best option provided to reflect an understanding of the term. It gives the client
something positive to strive towards and They provide the client with suggestions on
how to achieve their long and short term goals are incorrect as outcomes are nursingoriented, not client-oriented.
DIF: C
REF: 266
OBJ: Analysis
27. A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the
following statements best reflects an understanding of client-centered goals?
1. The clients A1C levels will be 7 or below at the first testing date.
2. The client will experience no blood sugar readings below 60 mg/dL before first
follow up visit.
3. The client will be visited weekly by home health nursing staff beginning 1 week
Test Bank
18-13
after discharge.
4. The client will demonstrate the ability to appropriately measure blood sugar levels
using a glucometer by discharge from nursing unit.
ANS: 4
A client-centered goal is a specific and measurable behavior or response that reflects a
clients highest possible level of wellness and independence in function, therefore The
client will demonstrate the ability to appropriately measure blood sugar levels using a
glucometer by discharge from nursing unit is correct. Although The clients A1C levels
will be 7 or below at the first testing date and The client will experience no blood sugar
readings below 60 mg/dL before first follow up visit are appropriate, they are not the
best options because they do not reflect independence in function. The client will be
visited weekly by home health nursing staff beginning 1 week after discharge is not
client-centered because it does not reflect a clients highest possible level of wellness and
independence in function.
DIF: C
REF: 267
OBJ: Evaluation
28. The expected outcome that best evaluates the presurgical goal of, Client will understand
purpose of coughing and deep breathing within 4 hours of returning to room is:
1. Client will demonstrate proper technique for coughing and deep breathing
2. Client will cough and deep breathe every 1 hour while awake without staff
prompting
3. Client is capable of restating the purpose of coughing and deep breathing in own
words
4. Clients lungs will be free of abnormal breath sounds within 1 hour of being
returned to room
ANS: 2
An expected outcome is a criteria designed to evaluate the achievement of the stated goal.
This option best represents evaluation of the clients understanding of the purpose of deep
breathing and coughing because it shows appropriate compliance. Although
demonstration evaluates the proper technique, it is not the best option to evaluate
understanding of purpose. Although restatement evaluates understanding, it is not the best
option to evaluate understanding of purpose because it does not include client
compliance. The clients lungs being free of abnormal breath sounds within 1 hour is
more reflective of a goal than of an expected outcome.
DIF: C
REF: 266
OBJ: Analysis
29. Which of the following statements made by the nurse best reflects an understanding of
the clients role in goal setting?
1. He knows what he needs better than anyone else.
Test Bank
18-14
2. When he sets the goals he is more likely to follow the plan.

3. He identifies the goals and then together we create the plan of action.
4. He is best suited to determine the level of effort he is capable of providing.
ANS: 4
Unless you set goals mutually and make a clear plan for action, clients will not follow the
care plan. Clients alone are not always appropriately prepared to set and plan goals
without professional help. Although the other answers may be true for many clients, it is
not a guarantee that the client possesses all the skills and knowledge necessary to set and
plan realistic goals.
DIF: C
REF: 267
OBJ: Analysis
30. A nurse is caring for a client who experienced short-term memory loss as a result of a
head injury. Which of the following statements made by the nurse regarding goal setting
requires follow-up by the nurse manager?
1. The client will certainly need frequent reorientation to the care plan goals.
2. I will restate the goals Ive created for him regularly so as to win his compliance.
3. Im not sure that his family will be able to support him with these goals but I will
discuss it with them.
4. He seems very willing to work towards achieving his goals but his condition will
certainly create barriers.
ANS: 2
If a client or significant other is not able to participate in goal development, you assume
responsibility until the client is able to participate. It is vital that to the degree that the
client is capable, the client be included in the decision-making process. Frequent
reorientation to the care plan goals may be true and so does not require follow-up. The
nurse seems pessimistic about the familys ability to play a role in the clients care plan
but declares that an attempt will be made to include them; so follow-up is not an
immediate priority. The client seems very willing to work towards achieving his goals
may be true and so does not require follow-up because there is no indication of the
nurses intention to minimize his participation.
DIF: C
REF: 265
OBJ: Analysis
31. Which of the following goals best shows that the nurse understands the concept of a
client-centered goal?
1. Client will consume at least 75% of each meal served.
2. ADLs will be completed before breakfast is served.
3. Pain will be managed so as to be rated at 3 or less out of 10.
4. Client will be transported to physical therapy by 9 AM daily.
ANS: 1
Test Bank
18-15
Client will consume at least 75% of each meal served is correct. Outcomes and goals
reflect the clients behavior and responses expected as a result of nursing interventions.
Write a goal to reflect client behavior, not to reflect your goals or interventions. The other
options are nursing-centered.
DIF: C
REF: 267
OBJ: Analysis
32. Which of the following client-centered goals best rest reflects singular focus?
1. Client will cough and deep breathe every hour while awake.
2. Client will be free of shoulder and elbow pain by discharge.
3. Client will adhere to a low-fat diet and lose 3 pounds in 30 days.
4. Client will ambulate to the bathroom for the purpose of showering daily.
ANS: 4
Each goal and outcome addresses only one behavior or response. In this case the client
will walk to the shower daily. Although coughing and deep breathing are usually done as
a unit, they are really two separate actions. The client being free of shoulder and elbow
pain by discharge relates to two different anatomical locations. Adhering to a diet and
losing 3 pounds are two different actions.
DIF: C
REF: 267
OBJ: Analysis
33. The nurse realizes that goals should be singular in focus primarily because:
1. The nurse will find it difficult to modify the plan of care if the goals are not met.
2. The client may not have the strength to accomplish multiply behavioral changes.
3. The client may have difficulty focusing on more than one behavioral modification
at a time.
4. The nurse will find it difficult to identify appropriate interventions to address
multiple behaviors.
ANS: 1
The nurse finding it difficult to modify the plan of care if the goals are not met is correct.
Singularity allows you to decide if there is a need to modify the plan of care because only
one response is considered. Although the other answers may be true, they are not the
primary reason for having only one focus per goal.
DIF: C
REF: 267
OBJ: Analysis
34. Which of the following goals concerning client anxiety is the best example of
measurability?
1. Client will be less anxious by discharge.
Test Bank
18-16
2. Client will appear less anxious by discharge.

3. Client will report anxiety at less than 3 out of 5 by discharge.
4. Client pulse rate and blood pressure will be within normal limits by discharge.
ANS: 3
You need to be able to observe if change takes place in a clients status. Observable
changes occur in physiological findings and the clients knowledge, perceptions, and
behavior. You observe outcomes by directly asking clients about their condition or by
using assessment skills. The client rating his anxiety is one method of observing
improvement. The phrase will be less anxious is not observable. The phrase will
appear less anxious is not observable. Although pulse rate and blood pressure may be
affected by anxiety, there is no assurance that normal readings reflect an improvement.
DIF: C
REF: 267
OBJ: Anxiety
35. Which of the following goals best reflects measurability?
1. Clients emotional state will be stable by time of discharge.
2. Client will experience normal sensations in feet by discharge.
3. Client will report being free of shoulder pain by discharge.
4. Client will have acceptable range of motion in elbow by discharge.
ANS: 3
Terms describing quality, quantity, frequency, length, or weight allow you to evaluate
outcomes precisely. Pain free relates to quantity as well as quality. Do not use vague
qualifiers such as normal, acceptable, or stable in an expected outcome statement.
Vague terms result in guesswork in determining a clients response to care.
DIF: C
REF: 267
OBJ: Analysis
36. When developing appropriate nurse-initiated interventions for a client admitted to an
acute care facility for abdominal pain, the nurse must first consider:
1. The institutions policies and procedures
2. The states defined scope of nursing practice
3. The clients physiological and psychological needs
4. The scientific rationale for the proposed nursing action
ANS: 2
Each state within the United States has developed a Nurse Practice Act that defines the
legal scope of nursing practice (see Chapter 22). According to the Nurse Practice Act in a
majority of states, independent nursing interventions pertain to activities of daily living,
health education and promotion, and counseling. Although the other answers must be
considered, they are not the first consideration.
DIF:
REF: 268
OBJ: Analysis
Test Bank
18-17

37. The nurse realizes that the primary nursing responsibility regarding a physician-initiated
intervention is to:
1. Facilitate the intervention in a timely manner
2. Evaluate the clients response to the intervention
3. Possess the technical skills required to implement the intervention
4. Provide client education regarding the implementation of the intervention
ANS: 3
Each physician-initiated intervention requires specific nursing responsibilities and
technical nursing knowledge. Although the other options are expectations, they are not
the primary consideration.
DIF: C
REF: 268
OBJ: Analysis
38. The primary function of a care plan is to provide:
1. The client with continuity of care
2. The staff with written client-centered nursing interventions
3. An established criteria for the evaluation of nursing outcomes
4. An organized means of exchanging information between caregivers
ANS: 1
The nursing care plan enhances the continuity of nursing care by listing specific nursing
interventions needed to achieve the goals of care. Although the rest are functions, they are
not the primary function.
DIF: C
REF: 269
OBJ: Analysis
MULTIPLE RESPONSE
1. Which of the following characteristics are considered guidelines for the writing of
appropriate goals and outcomes? (Select all that apply.)
1. Singular
2. Realistic
3. Practical
4. Observable
5. Measurable
6. Meaningful
ANS: 1, 2, 4, 5
Test Bank
18-18
There are seven guidelines for writing goals and expected outcomes. The guidelines are
client-centered, singular, observable, measurable, time-limited, mutual, and realistic.
Practical and meaningful are not recognized characteristics
DIF: C
REF: 269
OBJ: Analysis

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Potter & Perry: Fundamentals of Nursing, 7th Edition

Maintaining regular bowel elimination

MSC: NCLEX test plan designation: Health Promotion and Maintenance

Applying adequate clothing to ensure the clients warmth

2. When he sets the goals he is more likely to follow the plan.

2. Client will appear less anxious by discharge.

TOP: Nursing Process: Planning

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