Fundamentals Nursing Prep U Chapter 13 Outcome Identification and Planning

The nurse is prioritizing the client's nursing diagnoses. Which nursing diagnosis has priority?

Ineffective Airway Clearance related to retention of secretions

A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client?

Ineffective Impulse Control

After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care?

It helps deliver holistic, goal-oriented, individualized care.

The nurse is developing a plan of care for a client. When planning care in the outcome identification phase, what does the nurse determine is the benefit of this phase?

It promotes the client being an active participant in care

The nurse, in collaboration with the client's family, is assigning priorities related to the care of the client. The nurse explains that when setting priorities it is important to look at the urgency of specific problems. What provides the best framework for prioritizing client problems?

Maslow's hierarchy of needs

The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?

Mr. Conner will demonstrate proper care of stoma by 29MAR2015.

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

Nursing Outcome Classification

A nurse is formulating a nursing plan of care for a client based on assessment data. When writing this plan, which would be most important for the nurse to include?

Nursing interventions

What are specific measurable and realistic statements of goal attainment?

Outcome criteria

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority?

Resolve the client's anxiety

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention?

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

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 her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?

Upon her admission to the hospital

Which of the following is categorized as a psychomotor outcome?

Within 2 days of education, the client's wife will demonstrate abdominal dressing change.

A nurse plans a series of muscle strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. Which action by the nurse may have led to failure to meet the outcome?

choosing actions that do not solve the problem

A nurse identifies outcomes of care for the hospitalized, postoperative client primarily to:

provide individualized care

The nurse is determining realistic nursing interventions for a client on bed rest after a colon resection. What interventions would best meet the needs of this client? Select all that apply.

• Assist the client with deep breathing exercises with the use of incentive spirometry every hour • Turn the client and change position every 2 hours • Provide the client with a pillow to splint the abdomen and assist with coughing every 2 hours

A nurse is writing outcomes for clients in a rehabilitation facility. Which guidelines should the nurse consider? Select all that apply.

• At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. • The nurse should write outcomes that are brief and specific and support the overall plan of care.

The nurse is writing outcomes that are measurable for a client. What verbs will the nurse use in order to write these outcomes? Select all that apply.

• Define • Verbalize

A nurse is using the Nursing Outcome Classification system to assist in planning a client's care. The nurse understands that each outcome includes which component? Select all that apply.

• Definition • Measurement scale • Indicators • Target time

A nurse writes down the following outcome for a depressed client: "By 6/9/12, the client will state three positive benefits of receiving counseling." This is an example of which of the following types of outcomes?

Affective

A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective?

Client will use chin tuck and double swallow for each bite.

Which intervention performed by the nurse is most appropriate for assisting a client in meeting physiologic needs based on Maslow's Hierarchy of Needs?

Cutting up food and opening drink containers for the client

A nurse is planning nursing interventions for patients on a busy hospital unit. Which guideline would the nurse follow when designing the plan of care?

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

A nurse is caring for a 48-year-old man 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?

Outcome evaluation

A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement?

Return the client to bed and provide pain relief measures.

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2015." Why is this outcome inadequate?

The outcome is not observable or measurable.

The nurse is developing goals for a newly admitted client with visual and auditory hallucinations. Which outcome is the priority for the client?

Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior

The nurse assigned to care for a client has established client outcomes and outcome criteria. After completing this task, what would the nurse do next?

Write a client plan of care

The nurse is caring for Isabel, a 45-year-old ventilator-dependent quadriplegic. The nurse is in the process of placing IV access when the ventilator alarms occlusion. The nurse assesses Isabel and she appears mildly uncomfortable but is not in acute distress. What is the nurse's priority in the nursing outcome planning?

Assess tracheostomy for patency.

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority?

By day 2 of admission the client will remain safe and without injury from withdrawal symptoms

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer?

By discharge, client will perform hand hygiene before and after port care.

A nurse administers clonidine according to the standardized plan of care for a client admitted with hypertension. Which assessment information deviates from the expected client outcome for the first 24 hours and requires nursing intervention?

Client gains 1 kg (2.2 lb) in 1 day

The nurse is writing care plans for clients in the team. Which is an appropriate expected outcome for a client?

Client will independently follow transplant medication schedule 1 week after surgery.

The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome?

Client will maintain nutritional intake without pain or diarrhea.

A client is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes?

Family

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?

Perform hourly neurovascular assessment.

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 assistance with position change is provided every 2 hours to prevent pressure ulcers. What is the portion of "assistance to prevent pressure ulcers" portion of this statement described as?

rationale

A nurse is preparing an in-service program for a group of staff nurses who are returning to the workforce. As part of the in-service, the nurse will be describing the different types of client plans of care. Which element would the nurse include as common to any type of plan of care? Select all that apply.

• Nursing diagnoses • Client goals • Nursing interventions

A client has just given birth to a stillborn infant. The client is sobbing and states she feels God is punishing her for some bad choices in her past. She states she has always believed in God as a loving and caring presence in her life but now feels her faith is destroyed. Which nursing diagnoses would be included in the patient's care plan? Select all that apply

• Spiritual Distress • Grieving

The nurse is developing a plan of care for a newly admitted client to the nursing unit. The nurse knows that which elements are important to include in this plan of care? Select all that apply.

• promoting client participation • planning care that is realistic and measurable • allowing for involvement of support people