Chapter 16: Outcome Identification and Planning - ML4
A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? Educational Maintenance Surveillance Supervisory
Educational Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 112
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? Consult the oncology nurse specialist in order to determine priorities. Include the client and the client's power of attorney in the discussion. Ask the client what the priority needs are. Hold a unit meeting to determine needs.
Include the client and the client's power of attorney in the discussion. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 388
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. Client lipids are within range. Client is drowsy after lunch. Client reports no headache.
Client is normotensive. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 385
Which guideline should the nurse follow when including interventions in a plan of care? Make sure each nursing intervention does not describe the action the nurse should perform. Make sure the attending physician approves of and signs the nursing interventions. Make sure the nursing interventions are unrelated to the original outcomes. Date the nursing interventions when written and when the plan of care is reviewed.
Date the nursing interventions when written and when the plan of care is reviewed. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 396-397
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? Nurses do not carry out physician-initiated interventions. Nurses are not legally responsible for these interventions. Nurses are responsible for reminding physicians to implement orders. Nurses do carry out interventions in response to a physician's order.
Nurses do carry out interventions in response to a physician's order. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 397
What are specific measurable and realistic statements of goal attainment? Nursing interventions Outcomes Evaluations Nursing diagnoses
Outcomes Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 385
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? Set priorities using client care standards. Follow institutional guidelines. Seek research about the disorder. Consult with another nurse.
Seek research about the disorder. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 395-396
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? Ask the client's learning style, then teach diet information using that style. Present the client with videos and books about diet changes that reduce inflammation. Answer the client's questions about diet alterations, and then evaluate understanding. Start from client's knowledge, teach about diet modifications, and check for learning.
Start from client's knowledge, teach about diet modifications, and check for learning. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 387
Which is an example of a nurse-initiated intervention? Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. Administer a 1000-mL soap suds enema. Administer oxygen at 4 L/min per nasal cannula. Teach the client how to splint an abdominal incision when coughing and deep breathing.
Teach the client how to splint an abdominal incision when coughing and deep breathing. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 394-395
When establishing client outcomes with the client, what is the qualifier in the outcome? The outcome parameter The problem statement The short-term goal The long-term goal
The outcome parameter Explanation: The qualifier is a description of the parameter for achieving the outcome. Short-term and long-term goals and the problem statement are distinct from establishing client outcomes.
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. Tell another nurse about this client statement. Document that the depression has resolved. Encourage the client to join a therapy group.
Add the nursing diagnosis: Risk for Self-Harm. 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 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. Reference: Chapter 16: Outcome Identification and Planning - Page 390
A computerized information system developed to classify client outcomes is the: International Classification of Diseases NANDA-International list Nursing Outcome Classification system Clinical Care Classification System
Nursing Outcome Classification system Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 392
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? Provide oral pain medication before ambulation. Promote oral fluid intake between meals. Reassess in 4 hours and document the findings. Encourage hourly use of the incentive spirometer.
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. Reference: Chapter 16: Outcome Identification and Planning - Page 390
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? Once the client is admitted to the nursing unit from postanesthetic recovery As soon as possible after the client's surgery Once the client has received a discharge order On the client's admission to the hospital
On the client's admission to the hospital Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 390
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? Maintenance Psychosocial Surveillance Psychomotor
Psychomotor Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 393
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." "Client will list positive coping strategies and use them." "Client tries using relaxation as a means to cope." "Client will learn to cope more effectively."
"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. Reference: Chapter 16: Outcome Identification and Planning - Page 394
What behaviors reflect planning? Select all that apply. The nurse considers the developmental level of the client when selecting education materials. 1. The nurse assesses the client's usual sleep routine. 2. The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. 3. The nurse assists the client with bathing, grooming, and dressing. 4. The nurse decides to assist the client with ambulation in the hallway twice per shift. 5. The nurse considers the developmental level of the client when selecting education materials.
2, 4, 5 Explanation: Planning involves selecting evidence-based nursing interventions that will best address a client's problems as specified in the nursing diagnoses and thereby achieve the client's planned outcomes. Deciding to assist the client with ambulation, seeking input from the client and family on pain management, and considering a client's developmental level when selecting educational materials are all actions involving the nurse selecting interventions to best meet the client's needs. Assessing the client's usual sleep routine is an example of the assessment phase of the nursing process, not the planning phase. Assisting the client with bathing, grooming, and dressing is an example of the implementation phase of the nursing process, not the planning phase. Reference: Chapter 16: Outcome Identification and Planning - Page 388
Which outcome is sufficiently measurable? Client will maintain adequate intake with no reports of nausea by 12/15/2020. Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020. Client will progress from clear fluid diet to full fluid diet without experiencing nausea. Increase client's diet from clear fluids to full fluids by 12/15/2020.
Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020. Explanation: A fully measurable outcome should include a subject, verb, conditions, performance criteria, and target time (though not every outcome requires each parameter). Only the outcome "Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020" includes all appropriate components. The outcome "Client will progress from clear fluid diet to full fluid diet without experiencing nausea" lacks a target time. The outcome "Increase client's diet from clear fluids to full fluids by 12/15/2016" expresses the outcome as a nursing intervention. The outcome "Client will maintain adequate intake with no reports of nausea by 12/15/2016" does not define the performance criteria sufficiently, because "adequate intake" is an imprecise term. Reference: Chapter 16: Outcome Identification and Planning - Page 385-394
These nursing diagnoses appear on a client's care plan. Place in the order in which the nurse will prioritize acting upon them. Use all options. 1Risk for Impaired Skin Integrity 2Fluid Volume Deficit 3Impaired Swallowing 4Altered Body Image
Impaired Swallowing Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image Explanation: Maslow's hierarchy of needs can help nurses prioritize the sequence for addressing client needs. Basic physiologic needs, such as airway, breathing, and circulation, should be resolved before potential needs, or higher level needs such as self-esteem. Impaired swallowing is highest priority because the client may have difficulty ingesting both nutrition and fluids, and also has the potential for aspiration. A current need, such as fluid volume deficit, rates higher priority than a potential problem, risk for impaired skin integrity, or one higher on Maslow's scale, altered body image. Reference: Chapter 16: Outcome Identification and Planning - Page 390
Which are characteristics of appropriate client outcome statements? Select all that apply. Measurable Specific Short-term Realistic Broad in scope
Measurable specific realistic Explanation: Expected client outcomes should be specific (not broad in scope), measurable, realistic statements of goal attainment. They may restate the goal, but they also present information that will guide the evaluation phase of the nursing process. To be specific and measurable, certain requirements must be met when writing outcomes. Outcomes answer the questions who, what actions, under what circumstances, how well, and when. Outcomes may be short- or long-term and include a range of expectations about what the client's condition will be after nursing intervention. Reference: Chapter 16: Outcome Identification and Planning - Page 385
Which statement correctly describes a nurse-initiated intervention? Nurse-initiated interventions are actions performed to diagnose a medical problem. Nurse-initiated interventions are derived from the nursing diagnosis. Nurse-initiated interventions require a physician's order. Nurse-initiated interventions are actions deemed to have a low risk of harm to the client.
Nurse-initiated interventions are derived from the nursing diagnosis. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 394
A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered? Initial planning Ongoing planning Discharge planning Comprehensive planning
Ongoing planning Explanation: Ongoing planning is carried out by any nurse who interacts with the client. Its chief purpose is to keep the plan up-to-date to facilitate the resolution of health problems, manage risk factors, and promote function. The nurse caring for the client uses new data as they are collected and analyzed to make the plan more specific and accurate and, therefore, more effective. Comprehensive planning involves establishing a plan of care that addresses all aspects of the client's care needs and updating that plan of care as needed until the client is discharged. Comprehensive planning has three phases: Initial planning, ongoing planning, and discharge planning. Initial planning is performed by the nurse with the admission nursing history and the physical assessment and results in the development of a comprehensive plan of care that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate client goals and the related nursing care. In acute care settings, discharge planning begins when the client is admitted for treatment—or even before admission. It ensures that the nurse uses teaching and counseling skills effectively to help the client and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors at home competently. Reference: Chapter 16: Outcome Identification and Planning - Page 390
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 Isolation for suspected respiratory illness Septic workup due to blood pressure and heart rate elevation 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. Reference: Chapter 16: Outcome Identification and Planning - Page 389-390
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? Process Cost-effectiveness Outcome Structure
Outcome Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 408-409
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? Offer to help the client walk the length of the hallway each day. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. The client will become mobile within a 24-hour period. The nurse will help the client ambulate the length of the hallway once a day.
Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 394
A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest, and the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as? Nursing diagnosis Rationale Outcome Nursing intervention
Rationale Explanation: The nursing rationale is "why" a nursing intervention is to be performed. In this case, the reason for assisting with position changes is to prevent pressure injuries. The nursing diagnosis is the client's health problem that the client outcome and the nursing intervention must address. In this case, the likely nursing diagnosis would be Risk for Impaired Skin Integrity. The client outcome is the goal that the nursing interventions are attempting to achieve. In this case, the client outcome would be something like, "The client will not develop any pressure injuries before discharge." The nursing intervention is an action the nurse takes to address the client's health problem and achieve the client's outcomes. In this case, the nursing intervention is providing assistance with position change every 2 hours. Reference: Chapter 16: Outcome Identification and Planning - Page 396
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." Which nursing action is the priority? Provide preoperative education. Prepare the client for surgery. Evaluate the need for antibiotics. Resolve the client's anxiety.
Resolve the client's anxiety. Explanation: A priority is something that takes precedence in position, deemed the most important among several items. Resolving the client's anxiety is the priority because until it is resolved, the nurse may not be able to effectively provide preoperative education to the client, prepare the client for surgery, or evaluate the need for antibiotics. In fact, the client's anxiety may make it necessary to cancel the surgery altogether. Therefore, to have a successful outcome, the nurse must address the client's psychosocial issues related to anxiety. Reference: Chapter 16: Outcome Identification and Planning - Page 390
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? Supervisory Coordinating Psychosocial Supportive
Supportive Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 396-397
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? The client will demonstrate the correct use of a metered-dose inhaler. The client will ambulate 100 feet without supplementary oxygen or mobility aids. The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. The client will express an understanding of strategies for managing fatigue and shortness of breath.
The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 392
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 state when to notify the health care provider after discharge By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet.
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. Reference: Chapter 16: Outcome Identification and Planning - Page 394
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 To evaluate the plan of care developed To coordinate the nursing intervention To provide a basis for the scientific rationale
To design a plan of care to address the health problem Explanation: The primary purpose of the outcome identification and planning step of the nursing process is to design a plan of care with and for the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes. Reference: Chapter 16: Outcome Identification and Planning - Page 386-387
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? Posting the sign "NPO after midnight" over the bed Updating the diet orders in the client's plan of care Adding the diagnosis "Altered Nutrition, Less Than Required" Obtaining written consent for the diagnostic procedure
Updating the diet orders in the client's plan of care Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 408
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? Performance criteria Subject Verb (action) Conditions
Verb (action) Explanation: 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." Reference: Chapter 16: Outcome Identification and Planning - Page 393-394
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: comprehensive planning. discharge planning. ongoing planning. initial planning.
discharge planning. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 390
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: goal. intervention. evaluation. diagnosis.
intervention. Explanation: 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. Reference: Chapter 16: Outcome Identification and Planning - Page 394
