Chapter 13: Outcome Identification and Planning

The nurse asks if the client with a new diagnosis of lung cancer would like medication to help treat nicotine withdrawal symptoms. The client refuses by saying, "I have smoked since I was 12 years old. I am not going to stop now." What is the appropriate response by the nurse?

"Please tell me your thoughts about treating this diagnosis."

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

Identifies factors causing undesirable response and preventing desired change

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order.

A nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The nurse then uses the data to update the client plan of care. What are these actions considered?

Ongoing planning

An older adult female client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease (COPD). Which statement constitutes a long-term outcome?

The client will return home able to conduct her activities of daily living (ADLs) without experiencing shortness of breath.

A nurse identifies outcomes of care for the hospitalized, postoperative client primarily to:

provide individualized care.

The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I should call my health care provider if I have a sore that won't heal."

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

A nurse is caring for a client who is on the medical unit status post pneumonia. The client has a medical order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply.

-Auscultate for bowel sounds. -Begin feedings with clear broth. -Consult with dietitian regarding appropriate foods.

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer?

By discharge, client will perform hand hygiene before and after port care.

A nurse administers clonidine according to the standardized plan of care for a client admitted with hypertension. Which assessment information deviates from the expected client outcome for the first 24 hours and requires nursing intervention?

Client gains 1 kg (2.2 lb) in 1 day

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

Client is normal tensive.

Which is an appropriate expected outcome for a client?

Client will ambulate safely with walker in the room within 3 days of physical therapy.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

Which of the following outcomes is sufficiently measurable?

Client will tolerate a full fluid diet with no reports of nausea by 12/15/2016."

A nurse is planning nursing interventions for patients on a busy hospital unit. Which guideline would the nurse follow when designing the plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

Discharge planning

A client is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes?

Family

A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care?

Include the client and the client's power of attorney in the discussion.

The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?

Mr. Conner will demonstrate proper care of stoma by 29MAR2015.

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: T: 36.8°C sublingual, HR: 95, RR: 20, BP: 130/65. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. What order is the nurse likely to request first for the client?

Narcotic pain medication to treat pain

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

A nursing student is writing a care plan for an assigned client to be submitted to the instructor. Before submitting the care plan the student reviews it to ensure that all the necessary components have been addressed. Which component would the student look for? Select all that apply.

Nursing diagnoses Client goals Outcome criteria Interventions with rationales Evaluation

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?

Ongoing planning

What are specific measurable and realistic statements of goal attainment?

Outcome criteria

A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority?

Resolve the client's anxiety.

Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?

Standardized

The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?

Start from client's knowledge, teach about diet modifications, and check for learning.

A nurse is working with a client who is having a difficult time accepting her new diagnosis of type II diabetes. The nurse pulls up a chair next to the client's bed and holds her hand while listening to her story. What type of nursing intervention is the nurse engaging in?

Supportive intervention

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention?

Teach client how to splint abdominal incision when coughing and deep breathing.

A client is on the surgical unit s/p resection of an intestinal tumor. She is alert and oriented x3. Based on assessment of the client, a medical order to "ambulate with assistance" is written in the chart. This will be the client's first time ambulating. Which best represents a nursing outcome?

The client will ambulate with the assistance of a walker without falling within the next 4 hours.

A 63-year-old client in the ICU with a nursing diagnosis of risk for impaired skin integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to her left side she notices that the client has a non-blanching reddened area over her right trochanter. What would be the most appropriate action for the nurse to take?

The nurse repositions the client to her left side and updates the plan of care to turn and reposition the client every hour.

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?

Upon her admission to the hospital

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority?

Within 48 hours, client will recognize when additional tranquilizers are needed.

For which of the following clients would a standardized plan of care most likely be appropriate?

a client who was admitted for shortness of breath and who has been diagnosed with pneumonia

A nurse plans a series of muscle strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. Which action by the nurse may have led to failure to meet the outcome?

choosing actions that do not solve the problem

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

condition.

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

developing the plan without client input

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually:

does not contain documented scientific rationales.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention.

The nurse is developing a plan of care for a newly admitted client to the nursing unit. The nurse knows that which elements are important to include in this plan of care? Select all that apply.

promoting client participation planning care that is realistic and measurable allowing for involvement of support people

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?

to ambulate the client to a bedside chair

A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking, again." What is the priority nursing diagnosis?

Deficient Diversional Activity

A nurse is using the Nursing Outcome Classification system to assist in planning a client's care. The nurse understands that each outcome includes which component? Select all that apply.

-Definition - Measurement scale -Indicators

A nurse is writing an initial plan of care for a client with a rare condition. The nurse has little experience with the condition. What action by the nurse will result in the best plan of care?

Seek research about the disorder.

A nurse is caring for a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, three times per day, leads to expedited discharge. What type of evaluation best describes what the researchers are examining?

Outcome evaluation