The new nurse is caring for six patients in this shift. After ...

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The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
 
  a. Choose all the interventions and perform them in order of time needed for each one.
  b. Make sure you identify the scientific rationale for each intervention first.
  c. Decide on goals and outcomes you have chosen for the patients.
  d. Begin with the highest priority diagnoses, then select appropriate interventions.

Question 2

Which information indicates a nurse has a good understanding of a goal?
 
  a. It is a statement describing the patient's accomplishments without a time restriction.
  b. It is a realistic statement predicting any negative responses to treatments.
  c. It is a broad statement describing a desired change in a patient's behavior.
  d. It is a measurable change in a patient's physical state.

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Answer to Question 1

ANS: D
Work from your plan of care and use patients' priorities to organize the order for delivering interventions and organizing documentation of care. When developing a plan of care, the nurse needs to rank the nursing diagnoses in order of priority, then select appropriate interventions. Choosing all the interventions should take place after ranking of the diagnoses, and interventions should be prioritized by patient needs, not just by time. The chosen interventions should be evidence based with scientific rationales, but the diagnoses need to be prioritized first to prioritize interventions. Goals for a patient should be mutually set, not just chosen by the nurse.

Answer to Question 2

ANS: C
A goal is a broad statement that describes a desired change in a patient's condition or behavior. A goal is mutually set with the patient. An expected outcome is the measurable changes (patient behavior, physical state, or perception) that must be achieved to reach a goal. Expected outcomes are time limited, measurable ways of determining if a goal is met.