Answer to Question 1
Correct Answer: 3
Rationale 1: An informal nursing care plan is a strategy for action that exists in the nurse's mind.
Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the client's care.
Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. For example, all clients undergoing hip replacement surgery would have basic, similar needs or problems such as pain, skin integrity disruption, risk for infection, decreased mobility, or risk for fall or injury.
Rationale 4: An individualized care plan is tailored to meet the unique needs of a specific clientneeds not addressed by the standardized plan.
Answer to Question 2
Correct Answer: 4
Rationale 1: An informal nursing care plan is a strategy for action that exists only in the nurse's mind; this does not meet the needs expressed in the item.
Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the client's care; this does not meet the needs expressed in the item.
Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs.
Rationale 4: An individualized care plan is tailored to meet a specific client need that is not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine proceduresomething that is unplanned and a rare occurrence.
A client is having an endoscopy performed by a physician who views the upper gastrointestinal intern
An overall view of the four-cylinder engine that is due for a scheduled valve adjustment according ...
Testing the client’s ability to feel vibrations, the toe
Testing the Achilles tendon reflex with client in a supine position
Approaching the client for the ophthalmoscopic exam