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Test 4 Review CHP 10-14
Test 4 Review CHP 10-14
2.Examples include the uncertainty of the prognosis, lack of knowledge about the
condition and its treatment, and fear of pain.
3.Ineffective Airway Clearance or Breathing Pattern, Ineffective Coping, Spiritual
Distress, Hopelessness, (Readiness for Enhanced Comfort), Grieving.
4.Although this may be a true statement, lung cancer is a medical diagnosisnot a
nursing diagnosis, which is a response to health status or a health problem. In addition,
the stressor (related to) should be something the nurse can treat independently.
Chapter 13 Critical Thinking Page 232
1. What assumptions does the nurse make when deciding that using a
standardized care plan for Deficient Fluid
Volume is appropriate for this client?
2. Identify an outcome in the care plan and its nursing intervention that contribute
to discharge care planning.
What evidence supports your choice?
3. Consider how the nurse shares the development of the care plan and outcomes
with the client.
4. Not every intervention has a time frame or interval specified. It may be implied.
Under what circumstances is this acceptable practice?
5. In Table 131, Ineffective Airway Clearance is Amandas highest priority nursing
diagnosis. Under whatconditions might this diagnosis be of only moderate
priority in Amandas case?
Chapter 13
Critical Thinking Possibilities
1.The nurse assumes that the standardized care plan is comprehensive enough for this
client with the individualization that is applied to it.
2.The last outcome for Anxiety, Freely expressing concerns and possible solutions
about work and parenting roles, and the associated interventions are examples
because the roles described occur between the client and her family in the home rather
than in the hospital setting.
3.Several possibilities exist. The nurse needs to set aside time to discuss the plan with
the client, alone or with other family and health care team members. The plan can be
presented verbally or in writing. It can be initiated by the nurse who seeks validation
from the client. Or the problem list, nursing diagnoses, goals, outcomes, and
interventions can be decided on by the client and nurse together after the nurse
presents assessment data.
4.If agency guidelines delineate the frequency of nursing interventions and the care plan
does not require these more often than specified, no time frame is required. Also, if the
intervention is performed during every interaction (e.g., the nurse remains calm and
appears confident), no frequency need be written.
5.Nursing diagnoses related to airway are often the highest priority because they
represent life-threatening conditions. In reassessing priorities, the nurse considers new
problems as well as progress toward meeting existing goals. If the airway problem is in
the process of improving, other diagnoses may become higher priority