2023 ATI PN PEDIATRICS PROCTORED EXAM
(Detail Solutions)
1. The nurse completes a thorough assessment of a patient and analyzes the data
to identify
... [Show More] nursing diagnoses. Which step will the nurse take next in the nursing
process?
a. Assessment
b. Diagnosis
c. Planning
d. Implementation
ANS: C
After identifying a patient’s nursing diagnoses and collaborative problems, a nurse
prioritizes the diagnoses, sets patient-centered goals and expected outcomes, and
chooses nursing interventions appropriate for each diagnosis. This is the third step
of the nursing process, planning. The assessment phase of the nursing process
involves gathering data. The implementation phase involves carrying out
appropriate nursing interventions. During the evaluation phase, the nurse
assesses the achievement of goals and effectiveness of interventions.
2. A patient’s plan of care includes the goal of increasing mobility this shift. As the
patient is ambulating to the bathroom at the beginning of the shift, the patient
suffers a fall. Which initial action will the nurse take next to revise the plan of
care?
a. Consult physical therapy.
b. Establish a new plan of care.
c. Set new priorities for the patient.
d. Assess the patient.
ANS: D
Nurses revise a plan when a patient’s status changes; assessment is the first step.
Know also that a plan of care is dynamic and changes as the patient’s needs
change. Asking physical therapy to assist the patient is premature before assessing
the patient and awaiting the health care provider’s orders. The nurse may not
need to disregard all previous diagnoses. Some diagnoses may still apply, but the
patient needs to be assessed first. Setting new priorities is not recommended
before assessment and establishing diagnoses.
3. Which information indicates a nurse has a good understanding of a goal? It
is a statement describing the patient’s accomplishments without a
a. time restriction.
It is a realistic statement predicting any negative responses to
b. treatments.
It is a broad statement describing a desired change in a patient’s
c. behavior.
d. It is a measurable change in a patient’s physical state.
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.\
4. A nurse is developing a care plan for a patient with a pelvic fracture on bed
rest. Which goal statement is realistic for the nurse to assign to this patient?
a. Patient will increase activity level this shift
b. Patient will turn side to back to side with assistance every 2 hours. Patient will
use the walker correctly to ambulate to the bathroom as
c. needed.
Patient will use a sliding board correctly to transfer to the bedside
d. commode as needed.
ANS: A
A goal is a broad statement of desired change; the patient will increase activity
level is a broad statement. Turning is the expected outcome. When determining goals, the
nurse needs to ensure that the goal is individualized and realistic for the patient. Since the
patient is on bed rest, using a walker and bedside commode is contraindicated. [Show Less]