Chapter 19: Evaluating

Which nursing action would be most effective in helping a client learn self-care behaviors?

Model self-care behaviors for the client

Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement?

Psychomotor

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?

Surveillance

Which are cognitive client outcomes? Select all that apply.

The client lists the side effects of digoxin. The client describes how to perform progressive muscle relaxation. The client identifies signs and symptoms of hypoglycemia.

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation.

Which of the following best summarizes the evaluation step of the nursing process?

The nurse and client measure achievement of planned outcomes of care.

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?

"Demonstrated steps"

Which statement related to the evaluation of outcome attainment for a client is correct?

collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.

All of the activities listed are related to evaluation, but which evaluation activity is the priority concern for nurses?

measuring client outcome achievements with the client

"The levels of performance accepted by and expected of nursing staff or other health team members" defines:

standards.

A nurse caring for an older adult client who has dementia observes another nurse putting restraints on the client without a health care provider's order. The client is agitated and not cooperating. What would be the best initial action of the first nurse in this situation?

Confront the nurse and explain how this could be dangerous for the client.

An older adult client who is recovering from a stroke is scheduled to be transferred to the rehabilitation unit in the morning. The client is tearful and reports feeling lonely and abandoned in the hospital unit. The family visits daily, and flowers and cards are in the room. Documentation in the chart indicates that the client's pastor has been by twice in the past week to visit. Which nursing diagnosis and outcome criteria need to be addressed immediately for this client?

Ineffective Coping; verbalizes support systems.

While evaluating a client's plan of care, the nurse would be most likely to identify which problem as being associated with the implementation phase?

Nurses are not aware of client priorities and the plan of care.

A client with a new diagnosis of diabetes will be discharged on insulin therapy. Which client psychomotor outcome does the nurse expect after client education?

The client demonstrates administration of insulin.

A client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that the client has achieved a cognitive outcome in the management of this new health problem?

The client is able to explain when and why the client needs to check the blood glucose level.

Which characteristic is the most important indicator of high-quality nursing practice?

The nurse considers the individual needs of clients.

Which action by the nurse is an example of peer review?

The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.

Why are quality-assurance programs important in nursing?

They enable nursing to be accountable for the quality of care.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:

a cognitive outcome.

A group of nurses on the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. This program is termed:

Peer review

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated?

throughout the client's hospital admission

A mother brings an infant into the clinic for a well-infant visit. The mother reports being concerned at discharge from the hospital after giving birth about being able to get the infant to latch on for breastfeeding. Now, however, the mother reports success with breastfeeding and the nurse finds that the infant is gaining weight appropriately. Which is an appropriate evaluative statement for this client?

"8FEB2016. Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight."

The nursing staff on a hospital unit uses peer review to improve professional performance. Who performs the review?

Nurses

A nurse manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?

Another registered nurse with critical care certification

"The client will verbalize appropriate cast care on discharge" represents which type of outcome?

Cognitive

Which action should the nurse take during the evaluation phase of the nursing process?

Document reassessment of pain after medication administration.

The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan?

Evaluate the use of current pain relief measures.

A nurse finds that a client is not achieving the set outcomes for care and reviews the plan. Which are appropriate actions for the nurse to take while reviewing the plan of care? Select all that apply.

Modify the nursing diagnosis. Make the outcome statement more realistic. Adjust the time limits on the outcome statement Increase the complexity of the outcome statement.

A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement?

Physical changes

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?

Quality assurance

Which action should the nurse perform in the evaluation phase?

Revise the plan of care.

The nurse is implementing the nursing care plan with a client. Which of the nurse's actions best reflects evaluation?

The nurse assesses the client's response to pain medication.