Unit III Thoughtful practice and the process of care
316
nursing interventions need to be done and when they
must be done; and what teaching, counselling and
advocacy needs the person and family have.
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Answers with rationale
1.
The correct answer is
c
. Formulating and validating
identified health problems occur during the identifying
health problem phase of the process of care.
2.
The correct answer is
a
. If you fail to incorporate this
learning into the formal plan of care, other professional
carers will not be aware of the need to monitor the
person’s pain needs more closely. (b), (c) and (d) may
all be correct responses, but they should not be your
major concern.
3.
The correct answer is
c
. Ongoing planning is problem-
oriented and has as its purpose keeping the plan up to
date as new actual or potential problems are identified.
4.
The correct answer is
a
. Maslow’s hierarchy is (1) phys-
iological needs; (2) safety needs; (3) love and belonging
needs; (4) self-esteem needs; and (5) self-actualisation
needs. (2) is an example of a physiological need, (4) is
an example of a love and belonging need, (1) is an
example of a self-esteem need and (3) is an example of
a self-actualisation need.
5.
The correct answer is
a
. Goals are derived from the
problem statement of the identified health problem. For
each identified health problem in the plan of care, at least
one goal should be written that, if achieved, demon-
strates a direct resolution of the problem statement.
6.
The correct answer is
d
. Affective goals describe changes
in the person’s values, beliefs and attitudes. Cognitive
goals (
a
) describe increases in the person’s knowledge or
intellectual behaviours; psychomotor goals (
b
) describe
the person’s achievement of new skills. (
c
) is an outcome
describing a physical change in the person.
7.
The correct answer is
d
. Conditions specify the particu-
lar circumstances in or by which the outcome is to be
achieved. Not every outcome specifies conditions.
8.
The correct answer is
b
. Common errors when writing the
person’s goals include the following: (1) Expressing the
person’s goal as a nursing intervention. Incorrect: ‘Offer
Mr Myer 60 mL fluid every 2 hours while awake.’
Correct: ‘Mr Myer will drink 60 mL fluid every 2 hours
while awake, beginning 24/02/20XX.’ (3) Using verbs
that are not observable and measurable. Incorrect: ‘Mrs
Gaston will know how to bathe her newborn.’ Correct:
‘After attending the infant care class, Mrs Gaston will cor-
rectly demonstrate the procedure for bathing her
newborn.’Verbs to be avoided when writing goals include
‘know’, ‘understand’, ‘learn’ and ‘become aware’.
9.
The correct answer is
d
.
10.
The correct answer is
c
. (4) lacks sufficient detail to
effectively guide nursing intervention. The set of
nursing interventions written to assist the person to
meet an outcome must be comprehensive. Comprehen-
sive nursing interventions specify what observations
(assessments) need to be made and how often; what
