NUR 111 Introduction to Health Concepts

Correct Answer:

Nurse will ambulate with client, using a gait belt, twice daily for 15 minutes.

Explanation:

The best way to state a care plan intervention is in clear, specific, and measurable terms. The option “Nurse will ambulate with client, using a gait belt, twice daily for 15 minutes” specifies who will perform the action, what equipment will be used, how often the action will occur, and for how long. This clarity allows consistent implementation and evaluation of the intervention across caregivers.

Why Other Options Are Wrong:

Client will understand the rationale for using the gait belt.

This is incorrect because it represents a goal or expected outcome, not an intervention. Interventions describe nursing actions, while understanding reflects what the client should achieve. The nurse’s responsibility is to implement measurable actions, not simply to state what the client should know.

Client will ambulate in hallway twice daily.

This is wrong because it shifts responsibility onto the client without specifying the nurse’s role in providing assistance. A care plan intervention must reflect the nurse’s actions, not solely the client’s. Without clarity about support and safety measures, this statement is incomplete.

Nurse will assist the client with ambulation.

This option is incorrect because it is too vague. It lacks details about how the nurse will assist, the frequency, the duration, and the use of safety devices like a gait belt. Care plans require specific, measurable interventions to guide consistent nursing practice.

Correct Answer:

“Hello, I’m your nursing student and I’ll be helping to take care of you today.”

Explanation:

The best way to establish rapport is by greeting the client, introducing yourself, and clearly identifying your role. This builds trust, sets expectations, and promotes a professional relationship. By stating their name and role, the nursing student communicates respect and readiness to care for the patient.

Why Other Options Are Wrong:

“Hi. If you need anything, either your nurse or I will get it for you.”

This offers assistance but does not include a proper self-introduction or clarify the student’s role, which is essential when first meeting a client.

“You’re lucky, you have students and nurses taking care of you today.”

This is unprofessional and inappropriate. Rapport is built on respect and trust, not casual or dismissive remarks.

“Good morning, is there anything you need right now?”

While polite and helpful, this opening skips self-introduction and role clarification, leaving the client unclear about who the student is.

Correct Answer:

Fluid volume excess related to compromised regulatory system of the heart as evidence by edema in the lower extremities and weight gain.

Decrease cardiac output related to cardiac muscle damage secondary to myocardial infarction as evidence by EKG changes.

Ineffective airway clearance as evidence by decrease O2 saturation and increased respiratory rate.

Risk for constipation related to opioid use.

Explanation:

Fluid volume excess related to compromised regulatory system of the heart as evidence by edema in the lower extremities and weight gain.

This statement is correct because it follows the NANDA format: problem (fluid volume excess), etiology (compromised heart regulation), and defining characteristics (edema and weight gain). It provides a clear cause-and-effect relationship and measurable evidence that supports the diagnosis. The inclusion of observable symptoms such as edema and weight gain ensures that the diagnosis is specific and clinically valid.

Decrease cardiac output related to cardiac muscle damage secondary to myocardial infarction as evidence by EKG changes.

This is correct because it specifies the problem (decreased cardiac output), the underlying cause (cardiac muscle damage from MI), and the evidence (EKG changes). It is written in a structured manner and uses objective findings to support the diagnosis. This ensures that the nurse has identified both the physiological cause and the measurable clinical evidence that validates the diagnosis.

Ineffective airway clearance as evidence by decrease O2 saturation and increased respiratory rate.

This diagnosis is correct because it clearly identifies the problem (ineffective airway clearance), omits the “related to” phrase when the cause is evident, and supports the diagnosis with objective defining characteristics (low oxygen saturation and increased respiratory rate). Both signs can be measured and documented, making the statement clinically accurate and aligned with NANDA guidelines.

Risk for constipation related to opioid use.

This statement is correct because risk diagnoses do not include “as evidenced by” since the problem has not occurred yet. Instead, they identify the risk factor that places the client at risk—in this case, opioid use. The structure is accurate, concise, and reflects the proper NANDA format for risk diagnoses, making it a valid nursing diagnostic statement.

Why Other Options Are Wrong:

Acute Confusion secondary to stroke related to patient is confused.

This is incorrect because it restates the problem (“patient is confused”) instead of identifying actual contributing factors or measurable evidence. A correct statement would be written as “Acute Confusion related to decreased cerebral perfusion secondary to stroke as evidenced by disorientation and difficulty following commands.” The provided option lacks proper structure and does not meet diagnostic statement standards.

Correct Answer:

Ask an experienced nurse to assist with the care after reviewing the procedure.

Explanation:

The best action is to review the facility’s procedure for tracheostomy care and then seek assistance from an experienced nurse. This ensures patient safety, adherence to policy, and provides hands-on guidance while the nurse refreshes clinical skills. It allows the nurse to build competence in a supervised, safe manner without compromising the client’s care.

Why Other Options Are Wrong:

Ask for a different assignment until the nurse feels comfortable with this one.

This option is not appropriate because avoiding the assignment delays the nurse’s growth and responsibility. Nurses are expected to seek support and supervision, not decline patient care unless there is a risk of harm due to incompetence that cannot be resolved with assistance.

Do the best the nurse can by remembering what was taught in nursing school.

This is unsafe because knowledge from nursing school may not reflect current best practices or facility policies. Patient safety could be compromised if the nurse relies only on memory rather than updated procedures and experienced supervision.

Read the policy and procedure manual before caring for the client.

While reviewing the manual is important, reading alone is not sufficient when a nurse lacks recent hands-on practice. Without assistance from an experienced nurse, the nurse may make errors during care, especially in emergencies. Direct supervision is essential.

Correct Answer:

Discharge care plan.

Explanation:

A discharge care plan is initiated at admission and ensures patients receive coordinated care throughout their hospital stay and beyond. It addresses post-discharge needs, including medications, follow-up appointments, rehabilitation, and community resources. Planning early reduces complications, prevents readmission, and promotes continuity of care as the patient transitions to the next level of health services.

Why Other Options Are Wrong:

Student care plan.

This is designed as a learning tool for nursing students. It emphasizes the nursing process for practice and evaluation but is not a professional plan guiding patient transitions across care settings.

Interprofessional care plan.

While this involves collaboration among healthcare providers, its focus is on current care delivery rather than specifically preparing patients for discharge and linking them with community resources.

Standardized care plan/critical pathway.

These are generalized plans for managing patients with common conditions, providing consistency and efficiency. However, they are not individualized discharge plans that begin at admission and extend beyond hospitalization.

Correct Answer:

What worries you the most about your disease process?

Explanation:

Open-ended questions encourage patients to elaborate and provide more detailed responses, rather than a simple yes or no. Asking, “What worries you the most about your disease process?” allows the patient to describe their feelings, concerns, and experiences in their own words. This type of question facilitates therapeutic communication and helps the nurse gather meaningful information about the patient’s emotional and psychological state. It supports holistic assessment by going beyond factual data.

Why Other Options Are Wrong:

What medications are you currently taking?

This is incorrect because it is a closed-ended question that requires a specific factual response. The patient is expected to provide a list of medications, but it does not encourage elaboration or expression of feelings. While important for the health history, it does not explore broader concerns.

Do you have a health care power of attorney?

This is incorrect because it is also a closed-ended question, answerable with a simple “yes” or “no.” It does not invite further discussion or provide insight into the patient’s concerns or perceptions about their illness. While necessary, it is not open-ended communication.

Do you currently use any alcohol or tobacco products?

This option is wrong because it is structured as a closed-ended question. The patient can answer with “yes” or “no” or provide a short factual statement. Although clinically significant, it does not prompt the patient to expand on their thoughts or feelings.

Correct Answer:

Nursing Interventions Classifications (NIC).

Explanation:

The Nursing Interventions Classification (NIC) system provides a standardized language for nursing interventions. It allows nurses to clearly document, organize, and communicate treatments and actions across healthcare teams. NIC improves consistency, supports evidence-based practice, and ensures that interventions are clearly defined and understood in all clinical settings.

Why Other Options Are Wrong:

Quality and Safety Education for Nurses (QSEN).

QSEN is an educational initiative focused on preparing nurses with the knowledge, skills, and attitudes for quality and safety in healthcare. It is not a standardized communication system.

Clinical Practice Guidelines.

These are evidence-based recommendations for managing specific conditions. They provide direction for care but are not a standardized nursing language system.

Dependent Nursing Interventions.

These require a provider’s order and are part of nursing care, but they do not represent a communication framework or classification system.

Correct Answer:

Determining if the medication can be diluted in a beverage.

Explanation:

The nurse demonstrates critical thinking by first considering if the medication can be safely diluted in a beverage. This approach addresses the immediate barrier while maintaining patient compliance and safety. It is a problem-solving step that uses nursing judgment to adapt the medication administration in a way that makes it more acceptable to the client without delaying or compromising treatment.

Why Other Options Are Wrong:

Asking the nurse manager how to approach the situation.

This is not the best first action because the nurse is expected to use critical thinking to address common issues like medication refusal. Seeking managerial input may be necessary later if alternatives fail, but the nurse should first consider safe, independent interventions.

Waiting until the client is more cooperative.

This is unsafe because delaying medication could compromise treatment effectiveness. Essential medications must be given as prescribed, and simply waiting does not resolve the client’s resistance or demonstrate active problem-solving.

Notifying the health-care provider that the client has refused the medication.

While communication with the provider may be required if the nurse cannot resolve the issue, this should not be the first step. Nurses are responsible for exploring safe alternatives before escalating to the provider, making this option premature as the initial action.

Correct Answer:

The client will lose 5 pounds within the next 2 weeks.

Explanation:

Correctly written outcomes must be client-centered, specific, measurable, realistic, and time-bound (SMART criteria). “The client will lose 5 pounds within the next 2 weeks” clearly defines who (the client), what (lose weight), how much (5 pounds), and by when (within 2 weeks). This outcome is measurable and realistic, allowing the nurse to evaluate whether the goal is achieved. It represents a properly constructed desired outcome statement.

Why Other Options Are Wrong:

The client will be adequately hydrated by discharge.

This is incorrect because “adequately hydrated” is vague and not measurable. Adequate hydration could mean different things to different providers. A more specific outcome would state measurable indicators such as urine output, skin turgor, or lab values.

The client will walk better after resting for 10 minutes.

This option is wrong because it is subjective and unclear. “Walk better” does not define measurable progress and cannot be evaluated objectively. Outcomes should specify measurable distances or times, such as “The client will ambulate 50 feet with minimal assistance after 10 minutes of rest.”

The nurse will provide emotional support at least 3 times each day.

This is incorrect because desired outcomes should describe what the client will achieve, not what the nurse will do. Nursing interventions belong in the plan of care, while outcomes must remain client-focused and measurable in terms of client behavior or condition.