Chapter 13: Outcome Identification and Planning

Outcomes: describe the expected status of health issues at a certain points in time after treatment is coomplete

clinical outcomes

Type of planning: systematic process of preparing the patient to leave the health care facility and for maintaining continuity of care

discharge planning

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? A) ongoing planning B) initial planning C) discharge planning D) outcome planning

A) ongoing planning

The nurse recognizes that identifying outcomes/goals must include: A) input from multidisciplnary team B) involvement of the client and family C) involvement of the nurse manager and other staff nurses D) input from the physician

B) involvement of the client and family

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? A) prepare the client for surgery B) resolve the client's anxiety C) provide the preoperative education D) evaluate the need for antibiotics

B) resolve the client's anxiety

The nurse assigned to care for a client has established client outcomes and outcome criteria. After completing this task, what would the nurse do next? A) establish priorities B) write a client plan of care C) determine client goals D) identify objectives

B) write a client plan of care

A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective? A) client will avoid straws and drink thickened liquids B) client will chew food well and use tongue to sweep C) client will use chin tuck and double swallow for each bite D) client will sit in chair for all meals and snacks

C) client will use chin tuck and double swallow for each bite

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? A) nurses are not legally responsible for these interventions B) nurses are responsible for remind physicians to implement orders C) nurses do not carry out physician-initiated interventions D) nurses do not carry out interventions in response to a physician's orders

C) nurses do not carry out physician interventions

A nurse is demonstrating foley catheter care to a client. Which type of nursing intervention does this best represent?A) surveillance B) maitenance C) supervisory D) educational

D) educational

intervention type: nurses also carry out treatments initiated by other providers such as pharmacists, respiratory therapists, or physician assitants

collaborative intervention

Outcomes: describe the person's ability to function in relation to the desired usual activities

functional outcomes

Type of planning: Developed by the nurse who performs the nursing history and physical assessment Addresses each problem listed in the prioritized nursing diagnoses Identifies appropriate patient goals and related nursing care

initial planning

Any treatment based upon clinical judgment and knowledge that the nurse performs to enhance patient client outcomes

nursing intervention

intervention type: the actions performed by the nurse

nursing intervention

planning types: carried out by the nurse interacting with the patient, keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function.

ongoing planning

intervention type: intervention initiated by the physician in response to a medical diagnosis but is carried out by a nurse

physician initiated intervention

Outcomes: focus on key factors that affect someone's ability to enjoy life and achieve personal goals

quality-of-life outcomes

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? A) psychological intervention B) supervisory intervention C) coordinating intervention D) supportive intervention

D) supportive intervention

Each nursing intervention should include

Date Verb- action to be performed Subject- who is to do it Descriptive phrase- how, when, where, how often, how long or how much

Nursing Interventions

1. monitor patient health status and response to treatment 2. reduce risks 3. resolve, prevent, or manage a problem 4. promote independence with activities of daily living 5. promote optimum sense of physical, psychological, and spiritual well being 6. Give patients the information they need to make informed decisions and be independent

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) a standardized care plan B) an order set C) guidelines D) an algorithm

A) a standardized care plan

The nurse is caring for a 48-year-old male client with a new colostomy. Which client goal for Mr. Conner is written correctly? A) Mr. conner will be able to care for stoma and cope with psychological loss by 29MAR2015 B) Mr. conner will demonstrate proper care of stoma by 29MAR2015 C) Mr. conner will know how to care for his stoma by 29MAR2015 D) Explain to Mr. conner the proper care of the stoma by 29MAR2015

B) Mr. conner will demonstrate proper care of stoma by 29MAR2015

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client and family's ability to cope. What action should the nurse take with this client? A) providing more information about diabetes B) comforting the client and the family C) asking the client if anyone in the family also has diabetes D) testing the client's glucose level

B) comforting the client and the family

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? A) "do you want to be discharged without treatment?" B) "you need to stop smoking for us to effectively combat this disease" C) "please tell me your thoughts about treating this diagnosis" D) "what are your plans for discharge?"

C) "please tell me your thoughts about treating this diagnosis"

A nurse is planning nursing interventions for clients on a busy hospital unit. Which guideline would the nurse follow when designing the plan of care? A) make sure the nursing interventions are separate entity from the original goal/outcomes B) make sure the nursing intervention does not describe the nursing action to be performed C) date the nursing interventions when written and when the plan of care is reviewed D) make sure the nursing interventions are approved of and signed by the attending physician

C) date the nursing interventions when written and when the plan of care is reviewed

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? A) consult with another nurse B) follow institutional guidelines C) set priorities using client care standards D) seek research about the disorder

D) seek research about the disorder

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which example is a nurse-initiated intervention? A) administer morphine sulfate 2 mg IV push every 3 hours as needed for pain B) administer oxygen 4L/min per nasal canula C) administer a 1000 mL soap suds enema D) teach client how to splint abdominal incision when coughing and deep breathing

D) teach the client how to splint abdominal incision when coughing and deep breathing