Chapter 16: Outcome Identification and Planning

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

"Client will identify one coping strategy to try by end of week."

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."

Which outcome statements are in the cognitive realm? Select all that apply.

- By 6/8/20, the client will describe a meal plan that is high in fiber. - Within 1 week after teaching, the client will list three benefits of quitting smoking. - After viewing the film, the client will verbalize four benefits of daily exercise.

Which are correctly written nursing interventions? Select all that apply.

-Provide 5 to 6 small meals daily. -Provide opportunities for the client to express concerns and verbalize feelings. -Reposition the client from side to side every hour around the clock.

The nurse is caring for a client with urinary retention. The nurse is carrying out the implementation step in the nursing process when taking which action(s)? Select all that apply.

-inserting a foley catheter -providing client education -administering medication as prescribed

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 plan designed to support the client physically -A plan derived from a consensus of opinions of all staff members -A plan with problems that are easily solved -A plan made in conjunction with the hospital's ethics committee

A plan designed to support the client physically Explanation 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.

Which elements are common to any type of plan of care? Select all that apply.

Client goals Nursing diagnoses Nursing interventions

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 normotensive.

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.

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse? -Encourage hourly use of the incentive spirometer. -Promote oral fluid intake between meals. -Provide oral pain medication before ambulation. -Reassess in 4 hours and document the findings.

Encourage hourly use of the incentive spirometer. Explanation: 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 possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

A computerized information system developed to classify client outcomes is the:

Nursing Outcome Classification system

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?

On the client's admission to the hospital

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?

Ongoing

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?

Opioid analgesic to treat pain

Which phase of the nursing process most involves establishing priorities? -Assessment -Diagnosis -Outcome identification and planning -Implementation

Outcome identification and planning Explanation: During outcome identification and planning, the nurse establishes priorities as well as client goals and outcomes. During this phase, the nurse also plans nursing interventions and writes the plan of care. Assessment involves data collection; diagnosis involves identifying client problems. Implementation involves putting the plan of care into action.

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?

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

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 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?

Supportive

Which is an example of a nurse-initiated intervention?

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

When creating a care plan, which is the purpose of identifying the client outcome?

To design a plan of care to address the health problem

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?

Verb (action)

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

educational

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

intervention.

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 plan designed to support the client physically

Which guideline should the nurse follow when including interventions in a plan of care?

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

A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse?

Encourage hourly use of the incentive spirometer.

What are specific measurable and realistic statements of goal attainment?

Outcomes

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

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?

The nurse has omitted the time frame.

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 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?

Add the nursing diagnosis: Risk for Self-Harm.

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client 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

For which client 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 client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy -A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem -A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia Explanation: 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.

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.

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

Cutting up food and opening drink containers for the client Explanation: 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.

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? -The client will understand the effects of smoking related to heart disease. -By 08/02, the client will state three therapeutic methods of reducing stress. -By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. -By 8/02, the client will state when to notify the health care provider after discharge

The client will understand the effects of smoking related to heart disease. Explanation: 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.

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

"Client will identify one coping strategy to try by end of week." Explanation: 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? -Interrupted Breastfeeding -Ineffective Thermoregulation -Altered Gas Exchange -Impaired Parenting

Altered Gas Exchange Explanation: 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? -By the next clinic visit, client will report taking antihypertensive medication. -After attending sibling classes, client will be happy about a new baby and demonstrate feeding. -Client will ambulate safely with walker in the room within 3 days of physical therapy. -Client will perform complete ostomy care while bathing on the second postoperative day.

Client will ambulate safely with walker in the room within 3 days of physical therapy. Explanation: 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 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? -Opioid analgesic to treat pain -Septic workup due to blood pressure and heart rate elevation -Isolation for suspected respiratory illness -Acetaminophen to treat pain and fever

Opioid analgesic to treat pain Explanation: 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.

Which action should the nurse perform during the planning step of the nursing process? -Interprets and analyzes the client data -Establishes a database for the client -Identifies client strengths and weaknesses -Selects nursing measures, including client education

Selects nursing measures, including client education Explanation: 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. The nurse interprets and analyzes the data and identifies client strengths and weaknesses during the diagnosis phase of the nursing process. Establishment of a database occurs during the assessment phase.

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

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. Explanation: 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.