Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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nursing interventions need to be done and when they must be done; and what teaching, counselling and advocacy needs the person and family have.

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

Bibliography

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Web resources

Australian Commission on Safety and Quality in Health Care (ACSQHC): www.safetyandquality.gov.au/ Australian Council on Healthcare Standards (ACHS): www.achs.org.au Cochrane Collaboration: www.cochrane.org Joanna Briggs Institute: www.joannabriggs.edu.au