Which of the following principles does the nurse use in selecting interventions for the care plan?

There is one best intervention for each goal/outcome.

Actions should address the etiology of the nursing diagnosis.

Interventions should be "doing" not just monitoring.

Always select independent interventions when possible.

Answer and Explanation

The Correct Answer is B

When selecting interventions for a care plan, the nurse should consider several principles. One important principle is that actions should address the underlying cause (etiology) of the nursing diagnosis. By addressing the root cause of the problem, interventions can be more eﬀective in achieving the desired outcomes. There is not necessarily one "best" intervention for each goal or outcome, as diﬀerent clients may have diﬀerent needs and respond diﬀerently to interventions. Interventions can include both "doing" actions and monitoring, and both independent and collaborative interventions may be appropriate depending on the situation.

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Correct Answer is ["A","B","E"]

Explanation

During an assessment of a client diagnosed with narcolepsy, the nurse should anticipate the following findings: Hallucinations at the onset of sleep, Sleep apnea, and Sudden attacks of sleep ². These are common symptoms of narcolepsy. The other options (A lack of rapid eye movement (REM) sleep and The urge to move the legs when trying to sleep) are not directly related to narcolepsy.

A. The client's urinary output will be increased. B. The client's urine will be a medium-amber color. C. The client's urine will have a strong ammonia odor. D. The client's urinary output will be decreased.

Correct Answer is A

Explanation

A diuretic is a medication that increases the production of urine by the kidneys. This can help reduce swelling (edema) by removing excess ﬂuid from the body. If a client is prescribed a diuretic for swelling of the lower extremities, the nurse should teach the client that the medication will increase their urinary output. This means that the client will need to urinate more frequently and may produce more urine than usual. The color and odor of the urine may also change, but these changes are not directly related to the eﬀect of the medication on urinary output.

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Which of the following principles does the nurse use in selecting interventions for the care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting an assessment on a client diagnosed with narcolepsy. The nurse should anticipate which of the following findings? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A client is prescribed a diuretic for swelling of the lower extremities. The nurse should teach the client about the eﬀect of the medication on the client's urinary output.

Correct Answer is A

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

A client is hospitalized with numerous acute health problems. According to Maslow's hierarchy of needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client?

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The nurse is caring for a postpartum client who is receiving pain medication through an epidural catheter. Which assessment finding should the nurse report immediately to the physician?

A nurse is assessing a client who has a fever, an infection of a ﬂank incision, and is in severe pain. Which type of pulse rate would the client most likely exhibit?

A client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counselling practice and work full-time. The nurse should realize that this client is demonstrating which aspect of values clarification?

A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate?

A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." One of the following statements demonstrates that the nurse appropriately evaluated this goal.