Chapter 16: Outcome and Identification Planning PrepU

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? a. Surveillance b. Maintenance c. Supervisory d. Educational

d. Educational Demonstrating, teaching, and observing a return demonstration are classified as educational interventions. The remaining terms refer to aspects of monitoring the client and do not apply to this scenario.

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning? a. Ongoing b. Initial c. Discharge d. Outcome

a. Ongoing Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning.

A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse? a. Perform hourly neurovascular assessment. b. Elevate the injured arm on a pillow. c. Apply ice to the casted extremity. d. Give prescribed pain meds.

a. Perform hourly neurovascular assessment. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. This client exhibited a possible complication of impaired peripheral tissue perfusion. The nurse modifies the plan of care to increase the frequency of assessment in order to identify further complication. While the other nursing interventions are routine comfort measures used following injury, they are not sufficient to treat the complication.

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: a. a guideline. b. an algorithm. c. a critical pathway. d. an order set.

a. a guideline. A guideline is defined as a broad, research-based practice recommendation that may or may not have been tested in clinical practice. An algorithm has intense specificity and provides no provider flexibility; it is used to manage high-risk groups within a cohort. A critical pathway represents a minimal practice standard for a specific client population. An order set includes preprinted provider orders used to expedite the order process.

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? a. Maintenance b. Surveillance c. Psychomotor d. Psychosocial

c. Psychomotor Psychomotor interventions include activities such as positioning, inserting, and applying. A psychosocial intervention focuses on supporting, exploring, and encouraging. Maintenance and surveillance are monitoring interventions.

What are specific measurable and realistic statements of goal attainment? a. Nursing diagnoses b. Nursing interventions c. Evaluations d. Outcomes

d. Outcomes Expected client outcomes are specific, measurable, realistic statements of a client's goal attainment. Nursing diagnoses, interventions, and evaluation do not apply to outcomes or goals of nursing care. Nursing diagnoses are statements describing a client's actual or potential health problems that the nurse can treat independently using nursing interventions. Nursing interventions are the actions nurses take to treat the client's health problems. Evaluations are assessments of the effectiveness of interventions in resolving clients' health problems.

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns? a. "Leaning forward may help you to breathe better." b. "Running short distances can help you breathe better." c. "Take short and shallow breaths instead of deep breathing." d. "Do not practice pursed lip breathing, as this is a contraindication."

a. "Leaning forward may help you to breathe better." COPD is a chronic inflammatory disease that causes obstructed airflow from the lungs. Symptoms of COPD include difficulty breathing, wheezing, cough, and mucus production. Leaning forward helps the diaphragm move easier, allowing more air to fill the lungs. This, in turn, will help the client to breathe better. Running may lead to more difficulty breathing. Walking is a more effective intervention to educate a client with COPD. Clients with COPD should be educated about pursed lip breathing. This is the practice of relaxing the neck and shoulder muscles, breathing in through the nose for a few seconds, and then blowing the air out through pursed lips.

For which client would a standardized plan of care most likely be appropriate? a. A client who was admitted for shortness of breath and who has been diagnosed with pneumonia b. A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy c. A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem d. A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident

a. A client who was admitted for shortness of breath and who has been diagnosed with pneumonia Standardized care plans are most appropriate for clients who are experiencing a common and specific health problem, such as pneumonia. Clients with multiple pathologies or symptoms of unknown etiology are unlikely to have their unique needs reflected in a standardized care plan.

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? a. A plan designed to support the client physically b. A plan derived from a consensus of opinions of all staff members c. A plan with problems that are easily solved d. A plan made in conjunction with the hospital's ethics committee

a. A plan designed to support the client physically An unconscious client who is unable to provide input into outcome identification depends on the nurse to make informed choices to support the client physically. This care plan would treat any life-threatening situations and act to prevent the development of unhealthy physical consequences. The nurse is in the best position to determine client needs and would not seek the opinion of all staff members or the ethics committee. The care plan would deal with all problems, not just those that are easily solved.

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care? a. Add the nursing diagnosis: Risk for Self-Harm. b. Tell another nurse about this client statement. c. Encourage the client to join a therapy group. d. Document that the depression has resolved.

a. Add the nursing diagnosis: Risk for Self-Harm. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates risk for self-harm, not resolution of the depression. The nurse will perform additional assessment and add the new nursing diagnosis to the care plan. Changing the care plan to incorporate this new data makes it the most effective for treating the client. Telling another nurse could assist in treatment, but is less formal and less effective, because the entire team needs access to this information. While group therapy may provide help, it does not address the client's current mental health status related to self-harm.

The nurse has identified short- and long-term goals for a client after surgery to remove a leg tumor. When determining interventions for the goals, which questions are important for the nurse to consider? Select all that apply. a. Are the interventions compatible with other planned therapies? b. Are the interventions evidence-based? c. Are the interventions realistic and do they require resources available to the nurse? d. Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background? e. Are the interventions valued by the nursing staff?

a. Are the interventions compatible with other planned therapies? b. Are the interventions evidence-based? c. Are the interventions realistic and do they require resources available to the nurse? d. Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background? When developing nursing interventions, the nurse should be sure that they are appropriate in relation to the nursing diagnosis and related client outcomes, as well as safe and efficient. The interventions should be consistent with evidence-based practice and realistic for delivery of care. They should be valued by the client and family, but not necessarily by the nursing staff. The interventions should be compatible with other planned therapies.

A nurse is developing the postoperative plan of care for a client admitted with a fractured hip who has undergone surgery to repair it. Which intervention would the nurse identify as a nurse-initiated intervention? Select all that apply. a. Assess the client's pain level every 2 hours. b. Administer prescribed opioid analgesic every 4 hours as needed. c. Turn the client every 2 hours per turning schedule. d. Teach the client how to perform relaxation as a pain relief strategy. e. Obtain complete blood count and chest x-ray in the morning.

a. Assess the client's pain level every 2 hours. c. Turn the client every 2 hours per turning schedule. d. Teach the client how to perform relaxation as a pain relief strategy. Nurse-initiated interventions are autonomous actions based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnoses and projected outcomes. They do not require a physician's order. Rather, they address factors that cause or contribute to the client's problems. Examples include assessing pain, turning a client, and teaching a client about relaxation. A physician-initiated intervention is one initiated by a physician in response to a medical diagnosis but is carried out by the nurse in response to a physician's order. Examples include writing a prescription for an opioid analgesic and ordering laboratory and diagnostic tests, such as a complete blood count and a chest x-ray.

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem? a. Client will alternate rest periods with exercise throughout the day. b. Client will increase protein intake in small frequent meals. c. Client will use oxygen by nasal cannula when short of breath. d. Client will consistently perform pulmonary exercises.

a. Client will alternate rest periods with exercise throughout the day. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will promote health in a client with COPD, the most direct resolution of activity intolerance is for the client to pace activities by alternating rest with exercise throughout the day.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? a. Client will have formed stools within 24 hours. b. Client will eat small meals of bland foods for 3 days. c. Client will identify the food that caused the condition within 3 hours. d. Client will maintain adequate hydration within 2 days.

a. Client will have formed stools within 24 hours. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal.

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem? a. Client will not leave the premises without a caregiver. b. Client will wear an ID bracelet with name and contact information. c. Client will identify landmarks that indicate location of home. d. Client will consistently return to the police station when lost.

a. Client will not leave the premises without a caregiver. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with dementia, the most direct resolution of wandering is for the client to remain in the presence of someone who can prevent wandering.

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's and family's ability to cope. What action should the nurse take with this client? a. Comfort the client and family. b. Provide more information about diabetes. c. Test the client's blood glucose levels. d. Ask the client whether anyone else in the client's family also has diabetes.

a. Comfort the client and family. Comforting skills are nursing interventions that provide stability and security during a health-related crisis. It is appropriate for the nurse to comfort a client who has recently been diagnosed with diabetes and the client's family. Providing more information about diabetes, testing the client's blood glucose levels, and asking the client whether anyone else in the client's family has diabetes are examples of communication, teaching, and assessment skills and would not address the client's need for security.

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs? a. Cutting up food and opening drink containers for the client b. Seeking input from the client regarding preferences for a snack c. Providing the mother the phone number for the Poison Control Center d. Assisting the client to validate feelings regarding treatment options

a. Cutting up food and opening drink containers for the client According to Maslow's Hierarchy of Needs, physiologic needs are essential to maintain life. These needs include oxygen, water, food, temperature, elimination, sexuality, physical activity, and rest. Cutting up food and opening drink containers for the client would meet the most basic need for food. The nurse is meeting safety needs by providing a mother with the phone number for the Poison Control Center. The nurse seeking input from the client regarding preferences for a snack is showing respect to the individual and meeting self-esteem needs. When assisting the client to validate feelings regarding treatment options, the nurse is acknowledging the uniqueness of the client and respecting the client's knowledge and feelings in solving problems to attain self-actualization.

Which actions should the nurse perform during the planning step of the nursing process? Select all that apply. a. Establishing priorities b. Collecting and interpreting client data c. Identifying expected client outcomes d. Selecting evidence-based nursing interventions e. Evaluating client responses to interventions f. Communicating the plan of nursing care

a. Establishing priorities c. Identifying expected client outcomes d. Selecting evidence-based nursing interventions f. Communicating the plan of nursing care During the planning phase of the nursing process the nurse establishes priorities, identifies and writes expected client outcomes, selects evidence-based nursing interventions, and communicates the plan of nursing care. Collecting and interpreting data describes the assessment and diagnosis phases of the nursing process. Evaluating client responses to interventions occurs during the evaluation phase.

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? a. Include the client and the client's power of attorney in the discussion. b. Ask the client what the priority needs are. c. Consult the oncology nurse specialist in order to determine priorities. d. Hold a unit meeting to determine needs.

a. Include the client and the client's power of attorney in the discussion. During the planning step of the nursing process, the nurse develops and prioritizes an individualized plan of care in partnership with the client, family, and others as appropriate. The client with mental or physical limitations should be included in the plan as much as possible. When there are cognitive limits, the client's power of attorney (POA) should also be included in the plans.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? a. Individualize the plan to the client. b. Expect to modify the plan significantly. c. Identify the appropriate nursing diagnoses. d. Include the rationale for the interventions.

a. Individualize the plan to the client. Standardized plans of care are written by a group of nurses who are experts in a given area of practice (e.g., obstetrics, rehabilitation, orthopedics). The plans are written for a client population with a specific medical diagnosis (e.g., total hip replacement, pressure injury, vaginal delivery, coronary artery bypass surgery). These experts identify the most common nursing diagnoses for this client population and write the goals and interventions usually necessary to resolve the problem. Each time a standardized plan of care is used, it must be individualized for a specific client. The danger of a standardized plan of care lies in the fact that it may not fit a specific client. Nurses must make judgments as to the degree to which standardized plans should be modified or whether they should not be used in individual cases. With a standardized plan of care, the most common nursing diagnoses have already been identified. Rationales are typically not included on clinical plans of care.

Which statement correctly describes a nurse-initiated intervention? a. Nurse-initiated interventions are derived from the nursing diagnosis. b. Nurse-initiated interventions require a physician's order. c. Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. d. Nurse-initiated interventions are actions performed to diagnose a medical problem.

a. Nurse-initiated interventions are derived from the nursing diagnosis. Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a physician's order. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. They are not performed to diagnose any problem, medical or otherwise, but to help prevent or resolve a problem identified in a nursing diagnosis and thereby to achieve the related expected client outcome.

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 the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? a. On the client's admission to the hospital b. Once the client has received a discharge order c. As soon as possible after the client's surgery d. Once the client is admitted to the nursing unit from postanesthetic recovery

a. On the client's admission to the hospital Discharge planning should begin when a client is admitted for treatment. All the other times listed are too late and are not consistent with a client who is able to understand the process of the hospitalization.

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? a. Opioid analgesic to treat pain b. Septic workup due to blood pressure and heart rate elevation c. Isolation for suspected respiratory illness d. Acetaminophen to treat pain and fever

a. Opioid analgesic to treat pain A sickle cell crisis is an extremely painful event. Most clients with sickle cell disease have an individualized opioid plan that will help them to receive opioids in an expedited manner when they present in crisis. The slight elevations in the client's blood pressure and heart rate are likely secondary to pain, not sepsis. There is no evidence of respiratory illness based on the information given. Acetaminophen is not strong enough to treat this client's pain; furthermore, the client does not have a fever.

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? a. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. b. The nurse will help the client ambulate the length of the hallway once a day. c. Offer to help the client walk the length of the hallway each day. d. The client will become mobile within a 24-hour period.

a. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. "Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse" has all of these characteristics. "The nurse will help the client ambulate the length of the hallway once a day" is not specific in whether assistance is required, is not timebound, and is not client-centered, in that the nurse is the subject of the sentence, not the client. "Offer to help the client walk the length of the hallway each day" is a nursing intervention, not a client outcome. "The client will become mobile within a 24-hour period" is not specific or measurable.

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? a. Start from client's knowledge, teach about diet modifications, and check for learning. b. Present the client with videos and books about diet changes that reduce inflammation. c. Ask the client's learning style, then teach diet information using that style. d. Answer the client's questions about diet alterations, and then evaluate understanding.

a. Start from client's knowledge, teach about diet modifications, and check for learning. The nursing interventions written to assist a client to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what assessments need to be made and what nursing interventions, including teaching, counseling, and advocacy, need to be done. They should also include evaluation of the outcome of the intervention. "Start from client's knowledge, teach about diet modifications, and check for learning" provides the most comprehensive intervention for this client, as it includes assessment of the client's current level of knowledge, teaching, and evaluation of the teaching. None of the other answer options includes all three of these elements.

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? a. Supportive b. Psychosocial c. Coordinating d. Supervisory

a. Supportive Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems. Coordinating interventions involve many different activities, such acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care.

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client? a. The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. b. The client will express an understanding of strategies for managing fatigue and shortness of breath. c. The client will ambulate 100 feet without supplementary oxygen or mobility aids. d. The client will demonstrate the correct use of a metered-dose inhaler.

a. The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. Long-term outcomes require a longer period (usually more than a week) to be achieved than do short-term outcomes. They also may be used as discharge goals, in which case they are more broadly written and communicate to the entire nursing team the desired end results of nursing care for a particular client. Resumption of ADLs in the home setting is characteristic of a long-term outcome. Explaining energy-conservation techniques, mobilizing in the hospital, and demonstrating correct medication administration are short-term outcomes that may be accomplished prior to discharge.

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. What goal written by the nurse requires revision? a. The client will understand the effects of smoking related to heart disease. b. By 08/02, the client will state three therapeutic methods of reducing stress. c. By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. d. By 8/02, the client will state when to notify the health care provider after discharge

a. The client will understand the effects of smoking related to heart disease. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable. The verbs in the distractors are all measurable. The correct response has a goal that the nurse will be unable to measure.

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent? a. Verb (action) b. Subject c. Conditions d. Performance criteria

a. Verb (action) The action is one of the essential pieces of an outcome statement. The verb "ambulate" in this case represents the action that the client will perform and that the nurse will monitor and evaluate. The subject refers to the one who performs the action, which is always the client. The conditions are the particular circumstances in or by which the client is to achieve the outcome, such as "with the assistance of a cane" and "during a physical therapy session." The performance criteria are the expected client behaviors or other manifestations described in observable, measurable terms, such as "without incident."

Which outcome statements are in the cognitive realm? Select all that apply. a. Within 1 week after teaching, the client will list three benefits of quitting smoking. b. By 6/8/20, the client will correctly demonstrate self-injecting insulin. c. After viewing the film, the client will verbalize four benefits of daily exercise. d. By 6/8/20, the client will describe a meal plan that is high in fiber. e. By 6/8/20, the client will correctly demonstrate ambulating with a walker.

a. Within 1 week after teaching, the client will list three benefits of quitting smoking. c. After viewing the film, the client will verbalize four benefits of daily exercise. d. By 6/8/20, the client will describe a meal plan that is high in fiber. Cognitive outcomes describe increases in client knowledge or intellectual behaviors. Listing benefits of quitting smoking, describing meal plans, and verbalizing benefits of exercise demonstrate increased client knowledge. Administering an injection and correctly ambulating with a walker demonstrates a psychomotor outcome.

Which is an example of a psychomotor outcome? a. Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. b. Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. c. The client will verbalize understanding of the need to continue to take medications as prescribed. d. The client's skin will remain smooth, moist, and without breakdown or ulceration.

a. Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. Outcomes may be categorized according to the type of change they describe for the client. Psychomotor outcomes describe the client's achievement of new physical skills, such as changing an abdominal dressing. Cognitive outcomes describe an increase in the client's knowledge, such as understanding the need to continue to take medications as prescribed. Affective outcomes describe changes in client values, beliefs, and standards, such as decreasing the number of cigarettes one smokes due to adopting a belief that smoking is harmful. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved, such as a client's skin not developing breakdown or ulceration.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: a. discharge planning. b. initial planning. c. ongoing planning. d. comprehensive planning.

a. discharge planning. Discharge planning begins at the time of admission with the nurse teaching the client and family specific skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse's admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship.

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. "You need to stop smoking for us to effectively combat this disease." b. "Please tell me your thoughts about treating this diagnosis." c. "Do you want to be discharged without treatment?" d. "What are your plans after discharge?"

b. "Please tell me your thoughts about treating this diagnosis." In the planning stage of the nursing process, the nurse must focus on the client's interests and preferences, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority? a. Client will discuss drinking habits in therapy sessions the day after admission. b. By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms c. Client will commit to completing a 12-step program within 24 hours of admission. d. Within 3 days, client will be discharged.

b. By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms Safety is a top client priority. About half of all clients with alcohol addiction may develop alcohol withdrawal, which can lead to delirium tremens (DTs) with an estimated 15% fatality rate. The client who can recognize the need for tranquilizers can be treated to avoid DTs. It is unrealistic to expect the client to begin a 12-step program only 48 hours after being admitted in withdrawal. Similarly, starting therapy the day after admission would be premature. There is no way of knowing if a 3-day admission is sufficient for the client's needs.

Which guideline should the nurse follow when including interventions in a plan of care? a. Make sure the nursing interventions are unrelated to the original outcomes. b. Date the nursing interventions when written and when the plan of care is reviewed. c. Make sure the attending physician approves of and signs the nursing interventions. d. Make sure each nursing intervention does not describe the action the nurse should perform.

b. Date the nursing interventions when written and when the plan of care is reviewed. Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The physician does not approve and sign the interventions, because they are nursing interventions.

Which action should the nurse perform during the planning phase of the nursing process? a. Assess the client's overall health. b. Identify measurable goals or outcomes. c. Analyze the client's response to medicines. d. Identify the client's health-related problems.

b. Identify measurable goals or outcomes. In the planning phase of the nursing process, the nurse identifies measurable goals or outcomes, prioritizes nursing diagnoses and collaborative problems, selects appropriate interventions, and documents the plan of care. The nurse assesses the client's overall health during the assessment step of the nursing process, not during the planning step. The nurse identifies the client's health-related problems during diagnosis and analyzes the client's response to medicines during the evaluation process.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? a. Nurses do not carry out physician-initiated interventions. b. Nurses do carry out interventions in response to a physician's order. c. Nurses are responsible for reminding physicians to implement orders. d. Nurses are not legally responsible for these interventions.

b. Nurses do carry out interventions in response to a physician's order. A physician-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the physician and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding physicians to implement orders, nurses may request a physician to implement an order or question an existing order by the physician if the nurse believes it is in the client's best interests.

A computerized information system developed to classify client outcomes is the: a. NANDA-International list b. Nursing Outcome Classification system c. International Classification of Diseases d. Clinical Care Classification System

b. Nursing Outcome Classification system The Nursing Outcome Classification system organizes outcomes according to categories, classes, labels, indicators, and measurement activities. The remaining options do not classify client outcomes. NANDA-International is an organization that develops standardized terminology for nursing diagnosis to ensure client safety and improve client outcomes. The International Classification of Diseases is a classification system for classifying diseases according to diagnosis codes. The Clinical Care Classification System is a standardized system of codes used to label discrete components of nursing practice.

A nurse is reviewing the plan of care for a client and notes: "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." The nurse should identify this statement as an example which element of nursing practice? a. Nursing diagnosis b. Outcome c. Intervention d. Evaluation

b. Outcome This statement is an example of an expected client outcome. Outcomes answer the questions who (the client), what actions (verbalizes), under what circumstances (to the staff), how well (accurately), and when (before discharge). A nursing diagnosis, which identifies a client health problem, would include a diagnostic label, related factors, and defining characteristics. An intervention would reflect an action or treatment the nurse performs to promote client outcomes. An evaluation is not a statement but rather a process of assessing the client's response to nursing interventions.

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. Seek research about the disorder. c. Follow institutional guidelines. d. Set priorities using client care standards.

b. Seek research about the disorder. While each option is appropriate, it is crucial to find research to support the plan before establishing priorities. The nurse planning care uses clinical reasoning to set priorities that incorporate standards and agency policies, identify and record expected client outcomes, select evidence-based nursing interventions, and record the plan of care.

The nurse recognizes that an example of a cognitive outcome is: a. The client demonstrates self-catheterization using clean technique by June 3. b. The client identifies three foods high in potassium by August 8. c. The client accurately measures the radial pulse for 1 minute by February 2. d. The client verbalizes increased confidence in testing glucose levels.

b. The client identifies three foods high in potassium by August 8. Cognitive outcomes describe increases in client knowledge or intellectual behaviors, such as identifying three foods high in potassium. Demonstrating self-catheterization and measuring the radial pulse are examples of psychomotor outcomes, whereby new skills are achieved. Affective outcomes describe changes in client values, beliefs, and attitudes, such as increased confidence.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome? a. The nurse has not made any error in writing the outcome. b. The nurse has omitted the time frame. c. The nurse has omitted the defining characteristics. d. The outcome should indicate what the nurse will do.

b. The nurse has omitted the time frame. Outcomes are client-centered, use action verbs, identify measurable performance criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted. Defining characteristics are a component of the nursing diagnosis, not a client outcome. Because outcomes are client-centered, they describe what the client will do, not what the nurse will do.

A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client? a. Posting the sign "NPO after midnight" over the bed b. Updating the diet orders in the client's plan of care c. Obtaining written consent for the diagnostic procedure d. Adding the diagnosis "Altered Nutrition, Less Than Required"

b. Updating the diet orders in the client's plan of care The plan of care communicates three different types of nursing care: care related to meeting basic human needs, care related to nursing diagnoses, and care that must be coordinated with medical and interdisciplinary providers. Nutrition is a basic human need. The temporary need to withhold food and fluid should be documented in the record. The other options are not the best, most direct methods for conveying this information to all who may need it.

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: a. identifies the unhealthy response preventing desired change. b. identifies factors causing undesirable response and preventing desired change. c. suggests client goals to promote desired change. d. identifies client strengths.

b. identifies factors causing undesirable response and preventing desired change. The cause of the client health problem is referred to as the etiology. The problem statement of the nursing diagnosis suggests the client goals, and the cause of the problem (etiology) suggests the nursing interventions. Identifying the unhealthy response preventing desired change would occur during the evaluation phase of the nursing process. Client strengths are identified during the nursing diagnosis phase.

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? a. "Client will learn to cope more effectively." b. "Client will list positive coping strategies and use them." c. "Client will identify one coping strategy to try by end of week." d. "Client tries using relaxation as a means to cope."

c. "Client will identify one coping strategy to try by end of week." An appropriate outcome includes the client, an action verb, the circumstances by which the outcome is to be achieved, the performance criteria, and time frame. Identifying one coping strategy to try by the end of the week meets these criteria. The statement about the client learning to cope more effectively is not measurable. The statement about listing positive coping strategies and using them includes more than one behavior to evaluate, making it difficult to evaluate achievement. The statement about using relaxation is vague and not really measurable.

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? a. Interrupted Breastfeeding b. Ineffective Thermoregulation c. Altered Gas Exchange d. Impaired Parenting

c. Altered Gas Exchange Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, circulation, or safety issues such as threats of self-harm. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. Lack of surfactant interferes with lung expansion and can reduce oxygenation in premature infants. Breastfeeding and temperature regulation are of lower importance than oxygenation. Parenting skills may be promoted when parents visit high-risk infants in the nursery.

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer? a. By the next clinic visit, the client will report needing antiemetic medication. b. After attending a cancer support group, the client will report being in a good mood. c. By discharge, the client will perform hand hygiene before and after port care. d. The client will schedule radiation therapy sessions and plan for chemotherapy.

c. By discharge, the client will perform hand hygiene before and after port care. Outcomes should be specific, measurable, attainable, realistic, and timebound. Demonstrating hand hygiene before and after port care is a specific and reasonably attainable goal. The other answer options lack at least one of these criteria. Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable, such as "know" and "understand."

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? a. Client reports no headache. b. Client is drowsy after lunch. c. Client is normotensive. d. Client lipids are within range.

c. Client is normotensive. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 and 120/80 mm Hg. The other options do not directly indicate successful control of hypertension.

Which is an appropriate expected outcome for a client? a. By the next clinic visit, client will report taking antihypertensive medication. b. After attending sibling classes, client will be happy about a new baby and demonstrate feeding. c. Client will ambulate safely with walker in the room within 3 days of physical therapy. d. Client will perform complete ostomy care while bathing on the second postoperative day.

c. Client will ambulate safely with walker in the room within 3 days of physical therapy. Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy meets all of these criteria. "After attending sibling classes, client will be happy about a new baby and demonstrate feeding" is incorrect because it includes more than one client behavior, one of which is not observable or measurable ("be happy"), does not include performance criteria related to how well the client is to demonstrate feeding, and has a vague time frame ("after attending sibling classes"). "By the next clinic visit, client will report taking antihypertensive medication" lacks specificity regarding how often the client should take the medication. "Client will perform complete ostomy care while bathing on the second postoperative day" is likely not attainable within the time frame specified and lacks specificity regarding care the client will provide, making it difficult for the nurse to measure the client's success.

A nurse administers colchicine according to the standardized plan of care for a client admitted with acute gouty arthritis of the right great toe. Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention? a. Uric acid level decreases. b. Client walks to the bathroom. c. Foot remains red and swollen. d. Client reports diarrhea.

c. Foot remains red and swollen. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for gouty arthritis is reduction in pain. Pain reduction may occur before reduction of redness and swelling is visible. Diarrhea is a possible toxic effect of colchicine.

A nurse is caring for a client 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? a. Process b. Structure c. Outcome d. Cost-effectiveness

c. Outcome An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the expected client outcome. A broad view of evaluation in health care includes three approaches, directed toward structure, process, and outcome, depending on the focus of evaluation and the criteria or standards being used. Process/implementation evaluation determines whether program activities have been implemented as intended. Cost-effectiveness evaluation compares the relative costs to the outcomes (effects) of two or more courses of action. Structure evaluation assesses the effectiveness of various health care structures.

Which statement on a plan of care should a nurse identify as a nursing intervention? a. The client self-administered insulin correctly following education. b. The client will correctly demonstrate deep-breathing exercises after education. c. Perform range-of-motion exercises to all of the client's joints each morning. d. Readiness for Enhanced Communication

c. Perform range-of-motion exercises to all of the client's joints each morning. A nursing intervention is a treatment that the nurse performs to enhance client outcomes, such as "Perform range-of-motion exercises to all of the client's joints each morning." "The client self-administered insulin correctly following education" is an evaluative statement that the nurse might document to indicate the effectiveness of client education related to insulin self-administration. "The client will correctly demonstrate deep-breathing exercises after education" is an expected client outcome. "Readiness for Enhanced Communication" is a health promotion nursing diagnosis.

A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client? a. The client will perform range of motion exercises 3 times per day. b. Passive abduction with assistance c. The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day. d. The client performed active range of motion exercises only twice today but states a goal of 3 times per day tomorrow.

c. The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day. Documentation should be specific. The evaluation is a form of communication with the multidisciplinary health care team that indicates how the client is progressing in meeting expected outcomes. The most detailed documentation of evaluation is the one that provides a numerical measure of the client's range of motion, along with the specific plan for continued evaluation. The remaining options are too general and vague while lacking accountability and stemming from the client perspective.

Which outcome for a client with a new colostomy is written correctly? a. Explain to the client the proper care of the stoma by 3/29/20. b. The client will know how to care for the stoma by 3/29/20. c. The client will demonstrate proper care of the stoma by 3/29/20. d. The client will be able to care for stoma and cope with psychological loss by 3/29/20.

c. The client will demonstrate proper care of the stoma by 3/29/20. Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: a. diagnosis. b. evaluation. c. intervention. d. goal.

c. intervention. A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance client goals and outcomes. Nursing diagnoses are statements of the client's actual or potential health problems that the nurse is seeking to address through interventions and are the overarching driver of goal-setting, care planning, and interventions. Evaluation, the final phase of the nursing process, involves assessing the client's response to interventions on an ongoing basis and making any necessary adjustments and changes to the nursing care plan.

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? a. "I will take insulin until my blood sugar levels are normal." b. "I will take my medications between meals for maximum effect." c. "I will mix insulin glargine with insulin lispro at bedtime." d. "I will test my glucose level before meals and use sliding scale insulin."

d. "I will test my glucose level before meals and use sliding scale insulin." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration and storage and conditions that require contact with the health care provider. Diabetes mellitus is a chronic disease, so the client who takes insulin should not expect to ever achieve a normal blood glucose level without taking insulin. The client should test blood glucose level before, not between, meals. Mixing different types of insulin is not necessary.

The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate? a. "Nursing interventions are selected based on the etiology in the nursing diagnosis and must be compatible with other therapies planned for the client." b. "The client's developmental level, values, beliefs, and cultural and psychosocial background should be considered when selecting nursing interventions." c. "Nursing interventions should be consistent with standards of nursing care and research findings." d. "Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

d. "Nursing interventions are pretty much the same for clients that have the same medical diagnosis." Nursing interventions should be based on the etiology in the nursing diagnosis, be compatible with other planned therapies, be consistent with standards of care and research, and individualized for the client.

Which is an example of a nurse-initiated intervention? a. Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. b. Administer oxygen at 4 L/min per nasal cannula. c. Administer a 1000-mL soap suds enema. d. Teach the client how to splint an abdominal incision when coughing and deep breathing.

d. Teach the client how to splint an abdominal incision when coughing and deep breathing. A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nurse-initiated interventions, such as teaching, do not require a physician's order. A physician's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

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: a. support system. b. medical orders. c. past medical history. d. condition.

d. condition. Because a person's condition changes, priorities change. Priorities are based on information collected during reassessment after recovery and assignment to the acute care setting. As the client heals these priorities can shift rapidly. The client's support system would have more of an impact on priorities of care once the client is being discharged to home, not while the client is in the acute care setting immediately after surgery. Both the client's medical orders and the client's nursing priorities change in response to the client's condition, rather than in response to one another. The client's past medical history, which doesn't change, is less likely to affect the nursing priorities of the client after surgery than the client's condition, which does change.