Test Bank 8th-ED Nursing Care Plans Guidelines for individualizing Client Care Across the Life Span by Marilynn E.Doonges-Alice C.Murr

Test Bank 8th-ED Nursing Care Plans Guidelines for individualizing Client Care Across the Life Span by Marilynn E.Doonges-Alice C.Murr



Nursing Care Plans Guidelines for individualizing Client Care Across the Life Span Test-Bank 8 ed by Marilynn E.Doonges, Alice C.Murr


Authors: Marilynn E.Doonges, Alice C.Murr

Edition: 8th

Product Description

Test Bank 8th-ED Nursing Care Plans Guidelines for individualizing Client Care Across the Life Span by Marilynn E.Doonges-Alice C.Murr


Acid-base imbalances respiratory, 195 metabolic, 483

AIDS, 709
Alcohol: acute withdrawal, 819 Alzheimer’s disease, 764
Amputation, 646
Anemia–iron deficiency, anemia of chronic

disease, pernicious, aplastic, hemolytic, 493 Angina (coronary artery disease, acute coronary

syndrome), 64 Anorexia nervosa, 369 Aplastic anemia, 493 Appendectomy, 344 Asthma, 120

Bariatric surgery, 396
Benign prostatic hyperplasia, 588
Bulimia nervosa, 369
Burns: thermal, chemical, and electrical—acute

and convalescent phases, 667

Cancer, 846
Cardiac surgery: postoperative care, 100 Cardiomyoplasty, 100
Cerebrovascular accident/stroke, 238 Chemical burns, 667
Cholecystectomy, 364
Cholecystitis with cholelithiasis, 357 Cholelithiasis, 357
Chronic obstructive pulmonary disease, 120 Cirrhosis of the liver, 445
Colostomy, 334
Coronary artery bypass graft, 100
Coronary artery disease, 64
Craniocerebral trauma–acute rehabilitative

phase, 220 Crohn’s disease, 321

Deep vein thrombosis, 111
Dementia (Alzheimer’s type or vascular), 764 Diabetes mellitus/diabetic ketoacidosis, 405 Diabetic ketoacidosis, 405
Disaster considerations, 876
Disc surgery, 262
Dysrthymias , 88

Eating disorders: anorexia nervosa/bulimia nervosa, 369

Eating disorders: obesity, 387 Electrical burns, 667 End-of-life care/hospice, 866 Enteral feeding, 469 Esophageal bleeding, 306 Extended care, 801

Fecal diversions: postoperative care of ileostomy and colostomy, 334

Fluid and electrolyte imbalances, 903 Fluid and electrolyte imbalances, 903 Fractures, 632

Gastrectomy/gastric resection, 317 Gastric bypass, 396
Gastric partitioning, 396 Gastroplasty, 396

Glaucoma, 204 Graves’ disease, 419

Heart failure: chronic, 48 Hemodialysis, 575 Hemolytic anemia, 493 Hemothorax, 154 Hepatitis, 434

Herniated nucleus pulposus (ruptured invertebral disc), 254

HIV-positive client, 697
Hospice, 866
Hypercalcemia (calcium excess), 927 Hyperkalemia (potassium excess), 921 Hypermagnesemia (magnesium excess), 932 Hypernatremia (sodium excess), 915 Hypertension: severe, 37

Hyperthyroidism (Graves’ disease, thyrotoxicosis), 419

Hypervolemia (extracellular fluid volume excess), 905

Hypocalcemia (calcium deficit), 924 Hypokalemia (potassium deficit), 918 Hypomagnesemia (magnesium deficit), 930 Hyponatremia (sodium deficit), 914 Hypovolemia (extracellular fluid volume

deficit), 908 Hysterectomy, 611

Ileostomy, 334
Inflammatory bowel disease: ulcerative colitis,

Crohn’s disease, 321 Iron deficiency anemia, 493

Laminectomy, 262
Laryngectomy (postoperative care), 160 Leukemias, 516
Lung cancer: postoperative care, 144 Lymphomas, 525

Mastectomy, 619
Metabolic acid-base imbalances, 483 Metabolic acidosis—primary base bicarbonate

deficiency, 483
Metabolic alkalosis—primary base bicarbonate

excess, 488
Minimally invasive direct coronary artery

bypass, 100
Multiple sclerosis, 290 Myocardial infarction, 74

Obesity, 387
Obesity: bariatric surgery–gastric partitioning/

gastroplasty, gastric bypass, 396

Pancreatitis, 458 Parenteral feeding, 469

Pediatric considerations, 890 Peritoneal dialysis, 570 Peritonitis, 349
Pernicious anemia, 493 Pneumonia, 131 Pneumothorax, 154

Primary base bicarbonate deficiency, 483 Primary base bicarbonate excess, 488 Primary carbonic acid deficit, 200 Primary carbonic acid excess, 195 Prostatectomy, 596

Psychosocial aspects of care, 749 Pulmonary emboli considerations, 111 Pulmonary tuberculosis, 186

Radical neck surgery: laryngectomy (postoperative care), 160

Renal calculi, 603
Renal dialysis, 560
Renal failure: acute, 536
Renal failure: chronic, 548
Respiratory acid-base imbalances, 195 Respiratory acidosis (primary carbonic acid

excess), 195
Respiratory alkalosis (primary carbonic acid

deficit), 200
Rheumatoid arthritis, 729 Ruptured invertebral disc, 254

Seizure disorders, 210
Sepsis, 686
Septicemia, 686
Sickle cell crisis, 503
Spinal cord injury (acute rehabilitative phase),

Stroke, 238
Substance dependence/abuse rehabilitation, 835 Surgical intervention, 782

Thermal burns, 667
Thrombophlebitis: deep vein thrombosis (including

pulmonary emboli considerations), 111 Thyroidectomy, 429
Thyrotoxicosis, 419
Total joint replacement, 655

Total nutritional support: parenteral/enteral feeding, 469

Transplantation considerations—postoperative and lifelong, 739

Tuberculosis, pulmonary, 186

Ulcerative colitis, 321
Upper gastrointestinal/esophageal bleeding, 306 Urinary diversions/urostomy (postoperative

care), 578
Urolithiasis (renal calculi), 603 Urostomy, 578

Valve replacement, 100
Vascular dementia, 764
Ventilatory assistance (mechanical), 173


Client Assessment Database

Provides an overview of the more commonly occurring etiology and coexisting factors associated with a specific medical and/or surgical diagnosis as well as the signs and symptoms and corresponding diagnostic findings.

Nursing Priorities

Establishes a general ranking of needs and concerns on which the Nursing Diagnoses are ordered in constructing the plan of care. This ranking would be altered according to the individual client situation.

Discharge Goals

Identifies generalized statements that could be developed into short-term and intermediate goals to be achieved by the client before being “discharged” from nursing care. They may also provide guidance for creating long-term goals for the client to work on after discharge.

Nursing Diagnosis

The general need or problem (diagnosis) is stated without the distinct cause and signs and symptoms, which would be added to create a client diagnostic statement when specific client information is available. For example, when a client displays increased tension, apprehension, quivering voice, and focus on self, the nursing diagnosis of Anxiety might be stated: severe Anxiety related to unconscious conflict, threat to self-concept as evidenced by statements of increased tension, apprehension; observations of quivering voice, focus on self.

In addition, diagnoses identified within these guides for planning care as actual or risk can be changed or deleted and new diagnoses added, depending entirely on the specific client information.

May Be Related to/Possibly Evidenced by

These lists provide the usual or common reasons (etiology) why a particular need or problem may occur with probable signs and symptoms, which would be used to create the “related to” and “evidenced by” portions of the client diagnostic statement when the specific situation is known.

When a risk diagnosis has been identified, signs and symptoms have not yet developed and therefore are not included in the nursing diagnosis statement. However, interventions are provided to prevent progression to an actual problem. The excep- tion to this occurs in the nursing diagnosis risk for Violence, which has possible indicators that reflect the client’s risk status.

Desired Outcomes/Evaluation Criteria—Client Will

These give direction to client care as they identify what the client or nurse hopes to achieve. They are stated in general terms to permit the practitioner to modify or individualize them by adding time lines and specific client criteria so they become “measurable.” For example, “Client will appear relaxed and report anxiety is reduced to a manageable level within 24 hours.”

Nursing Outcomes Classification (NOC) labels are also included. The outcome label is selected from a standardized nursing language and serves as a general header for the outcome indicators that follow.


Nursing Interventions Classification (NIC) labels are drawn from a standardized nursing language and serve as a general header for the nursing actions that follow.

Nursing actions are divided into independent—those actions that the nurse performs autonomously; and collaborative— those actions that the nurse performs in conjunction with others, such as implementing physician orders. The interventions in this book are generally ranked from most to least common. When creating the individual plan of care, interventions would nor- mally be ranked to reflect the client’s specific needs and situation. In addition, the division of independent and collaborative is arbitrary and is actually dependent on the individual nurse’s capabilities and hospital and community standards.


Although not commonly appearing in client plans of care, rationale has been included here to provide a pathophysiological basis to assist the nurse in deciding about the relevance of a specific intervention for an individual client situation.

Clinical Pathway

This abbreviated plan of care or care map is event- or task-oriented and provides outcome-based guidelines for goal achieve- ment within a designated length of stay. Several samples have been included to demonstrate alternative planning formats.


Activity Intolerance [specify level] Activity Intolerance, risk for Activity Planning, ineffective Airway Clearance, ineffective Allergy Response, latex

Allergy Response, risk for latex Anxiety [specify level]
Anxiety, death
Aspiration, risk for Attachment, risk for impaired Autonomic Dysreflexia Autonomic Dysreflexia, risk for Behavior, risk-prone health Bleeding, risk for

Body Image, disturbed
Body Temperature, risk for imbalanced
Bowel Incontinence
Breastfeeding, effective
Breastfeeding, ineffective
Breastfeeding, interrupted
Breathing Pattern, ineffective
Cardiac Output, decreased
Caregiver Role Strain
Caregiver Role Strain, risk for
Childbearing Process, readiness for enhanced Comfort, impaired
Comfort, readiness for enhanced Communication, impaired verbal Communication, readiness for enhanced Conflict, decisional
Conflict, parental role
Confusion, acute
Confusion, risk for acute
Confusion, chronic
Constipation, perceived
Constipation, risk for
Contamination, risk for
Coping, defensive
Coping, ineffective
Coping, readiness for enhanced
Coping, ineffective community
Coping, readiness for enhanced community Coping, compromised family
Coping, disabled family
Coping, readiness for enhanced family
Death Syndrome, risk for sudden infant Decision-Making, readiness for enhanced Denial, ineffective
Dentition, impaired
Development, risk for delayed
Dignity, risk for compromised human
Distress, moral
Disuse Syndrome, risk for
Diversional Activity, deficient
Electrolyte Imbalance, risk for
Energy Field, disturbed
Environmental Interpretation Syndrome, impaired Failure to Thrive, adult
Falls, risk for
Family Processes, dysfunctional
Family Processes, interrupted
Family Processes, readiness for enhanced Fatigue
Feeding Pattern, ineffective infant
Fluid Balance, readiness for enhanced
[Fluid Volume, deficient hyper/hypotonic]
Fluid Volume, deficient [isotonic]
Fluid Volume, excess
Fluid Volume, risk for deficient

Fluid Volume, risk for imbalanced Gas Exchange, impaired
Glucose Level, risk for unstable blood Grieving

Grieving, complicated
Grieving, risk for complicated
Growth, risk for disproportionate
Growth and Development, delayed
Health Maintenance, ineffective
Health Management, ineffective self [formerly

Therapeutic Regimen Management, ineffective] Health Management, readiness for enhanced self [formerly Therapeutic Regimen Management,

readiness for enhanced]
Home Maintenance, impaired
Hope, readiness for enhanced
Identity, disturbed personal
Immunization Status, readiness for enhanced Infant Behavior, disorganized
Infant Behavior, readiness for enhanced organized Infant Behavior, risk for disorganized
Infection, risk for
Injury, risk for
Injury, risk for perioperative positioning
Intracranial Adaptive Capacity, decreased Jaundice, neonatal
Knowledge, deficient [Learning Need] [specify] Knowledge [specify], readiness for enhanced Lifestyle, sedentary
Liver Function, risk for impaired
Loneliness, risk for
Maternal/Fetal Dyad, risk for disturbed
Memory, impaired
Mobility, impaired bed
Mobility, impaired physical
Mobility, impaired wheelchair
Motility, dysfunctional gastointestinal
Motility, risk for dysfunctional gastointestinal Nausea
Neglect, self
Neglect, unilateral
Noncompliance [Adherence, ineffective] [specify] Nutrition: less than body requirements, imbalanced Nutrition: more than body requirements, imbalanced Nutrition: more than body requirements, risk for

Nutrition, readiness for enhanced
Oral Mucous Membrane, impaired
Pain, acute
Pain, chronic
Parenting, impaired
Parenting, readiness for enhanced
Parenting, risk for impaired
Perfusion, ineffective peripheral tissue Perfusion, risk for decreased cardiac tissue Perfusion, risk for ineffective cerebral tisse Perfusion, risk for ineffective gastrointestinal Perfusion, risk for ineffective renal
Peripheral Neurovascular Dysfunction, risk for Poisoning, risk for
Post-Trauma Syndrome [specify stage] Post-Trauma Syndrome, risk for
Power, readiness for enhanced
Powerlessness [specify level]
Powerlessness, risk for
Protection, ineffective
Rape-Trauma Syndrome
(Rape-Trauma Syndrome: compound reaction—

retired 2009)

(Rape-Trauma Syndrome: silent reaction—retired 2009)

Relationship, readiness for enhanced Religiosity, impaired
Religiosity, risk for impaired Religiosity, readiness for enhanced Relocation Stress Syndrome Relocation Stress Syndrome, risk for Resilience, impaired individual Resilience, readiness for enhanced Resilience, risk for compromised Role Performance, ineffective Self-Care, readiness for enhanced Self-Care Deficit: bathing

Self-Care Deficit: dressing
Self-Care Deficit: feeding
Self-Care Deficit: toileting Self-Concept, readiness for enhanced Self-Esteem, chronic low Self-Esteem, situational low Self-Esteem, risk for situational low Self-Mutilation

Self-Mutilation, risk for
Sensory Perception, disturbed (specify: visual,

auditory, kinesthetic, gustatory, tactile, olfactory) Sexual Dysfunction
Sexuality Pattern, ineffective
Shock, risk for

Skin Integrity, impaired
Skin Integrity, risk for impaired
Sleep, readiness for enhanced
Sleep Deprivation
Sleep Pattern, disturbed
Social Interaction, impaired
Social Isolation
Sorrow, chronic
Spiritual Distress
Spiritual Distress, risk for
Spiritual Well-Being, readiness for enhanced Stress Overload
Suffocation, risk for
Suicide, risk for
Surgical Recovery, delayed
Swallowing, impaired
(Therapeutic Regimen Management, effective—

retired 2009)
(Therapeutic Regimen Management, ineffective

community—retired 2009)
Therapeutic Regimen Management, ineffective

Thermoregulation, ineffective
(Thought Processes, disturbed—retired 2009) Tissue Integrity, impaired
Transfer Ability, impaired
Trauma, risk for
Trauma, risk for vascular
Urinary Elimination, impaired
Urinary Elimination, readiness for enhanced Urinary Incontinence, functional
Urinary Incontinence, overflow
Urinary Incontinence, reflex
Urinary Incontinence, stress
(Urinary Incontinence, total—retired 2009) Urinary Incontinence, urge
Urinary Incontinence, risk for urge
Urinary Retention [acute/chronic]
Ventilation, impaired spontaneous
Ventilatory Weaning Response, dysfunctional Violence, [actual/]risk for other-directed Violence, [actual/]risk for self-directed Walking, impaired
Wandering [specify sporadic or continual]
[ ] author recommendations

Nursing Diagnoses—Definitions and Classification 2009–2011 © 2009, 2007, 2005, 2003, 2001, 1998, 1996, 1994 NANDA International. Used by arrangement with Wiley-Blackwell Publishing, a company of John Wiley & Sons, Inc. In order to make safe and effective judgments using NANDA-I nursing diagnoses, it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.



Test Bank 8th-ED Nursing Care Plans Guidelines for individualizing Client Care Across the Life Span by Marilynn E.Doonges-Alice C.Murr