Focus of the Planning Phase

Every question here, with the answer

1. A nurse is prioritizing care for several patients. Which patient need should the nurse address first?

   1. A patient with an ineffective airway who may need immediate life-support protocols
   2. A patient who needs discharge teaching about long-term lifestyle changes
   3. A patient who is upset after an argument and says they may not eat lunch
   4. A patient with chronic constipation who needs a bowel plan reviewed

   Answer: A patient with an ineffective airway who may need immediate life-support protocols

   Airway, breathing, and circulation are the highest priorities in planning care because they are necessary for life. Emotional distress, chronic needs, and discharge teaching are important, but they do not take priority over an ABC need.

2. A nurse is developing a plan of care and wants it to reflect evidence-based practice. Which actions are appropriate? Select all that apply.

   1. Consider core measures related to the patient’s specific condition or diagnosis
   2. Use opinion rather than evidence when explaining the plan to the patient
   3. Use current and best evidence to guide patient care implementation
   4. Use a clinical pathway for a commonly treated condition when applicable
   5. Rely on historical routines because they have always been used on the unit

   Answer: Consider core measures related to the patient’s specific condition or diagnosis, Use current and best evidence to guide patient care implementation, Use a clinical pathway for a commonly treated condition when applicable

   Evidence-based planning uses current best evidence, clinical pathways, and core measures to support safe and predictable care. Relying on historical routines or opinion is not consistent with the section’s description of EBP.

3. A patient is crying after an argument with their significant other and says, “I may not even be able to eat lunch today because I am too upset to think about food.” The nurse has ruled out an ABC problem. What should the nurse prioritize?

   1. The possibility that the patient might miss lunch later
   2. Discharge planning needs
   3. A long-term nutrition plan
   4. The patient’s current emotional distress

   Answer: The patient’s current emotional distress

   The patient’s emotional distress is occurring now, while not eating lunch is only a potential problem at this point. The section emphasizes prioritizing the actual, current problem over the potential one.

4. The nurse is identifying outcomes for a patient’s individualized plan of care. Which outcomes or planning actions are consistent with the section? Select all that apply.

   1. Include the patient’s input when possible when setting the outcome time frame
   2. Set a time frame so the intervention can be evaluated at the end of that period
   3. Choose outcomes that are reasonable and attainable for the specific patient
   4. Expect every patient who has minor surgery to walk afterward, regardless of baseline ability
   5. Create outcomes without considering the patient’s unique qualities and needs

   Answer: Include the patient’s input when possible when setting the outcome time frame, Set a time frame so the intervention can be evaluated at the end of that period, Choose outcomes that are reasonable and attainable for the specific patient

   Outcomes should be realistic, individualized, and tied to a time frame so the nurse can evaluate effectiveness. The section warns that outcomes must fit the specific patient’s abilities, needs, and situation.

5. A nurse sits with a patient newly diagnosed with diabetes while the patient chooses foods from a list that fit the diagnosis. The nurse listens, supports the decision-making process, and praises correct choices. Which care coordination role is the nurse demonstrating?

   1. Counselor
   2. Educator
   3. Communicator
   4. Interdisciplinary team member

   Answer: Counselor

   The counselor role includes helping the patient make decisions that promote health and providing encouragement and support. Teaching a skill, reporting to team members, or simply explaining information would reflect other roles.

6. A nurse is participating in comprehensive planning for a hospitalized patient. Which actions match the types of planning described in the section? Select all that apply.

   1. Address each problem in a nursing diagnosis format during initial planning
   2. Mark completed parts of the plan during ongoing planning
   3. Limit discharge planning to the nurse only, without the interdisciplinary team
   4. Identify which parts of the plan of care need revision during ongoing planning
   5. Use discharge planning to identify what will happen after the patient leaves the facility

   Answer: Address each problem in a nursing diagnosis format during initial planning, Mark completed parts of the plan during ongoing planning, Identify which parts of the plan of care need revision during ongoing planning, Use discharge planning to identify what will happen after the patient leaves the facility

   Initial planning addresses problems, prioritizes interventions, and identifies outcomes. Ongoing planning revises or completes parts of the plan, while discharge planning identifies needs after discharge and involves the interdisciplinary team.