N400 Ch16: Outcome Identification and Planning

10. 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."

25. 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."

21. What verbs should the nurse use to write outcomes that are measurable? Select all that apply.

-Verbalize -Define

24. 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.

3. 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.

19. 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.

28. Which client outcome requires modification

By the end of instruction, client will know how to perform dressing changes.

7. 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.

44. Which is an appropriate expected outcome for a client?

Client will ambulate safely with walker in the room within 3 days of physical therapy.

5. 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.

8. 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.

31. Which action should the nurse perform during the planning phase of the nursing process?

Identify measurable goals or outcomes.

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

Nursing Outcome Classification system

39. Which phase of the nursing process most involves establishing priorities?

Outcome identification and planning

12. What are specific measurable and realistic statements of goal attainment?

Outcomes

26. What are specific measurable and realistic statements of goal attainment?

Outcomes

27. According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is:

Physiological

23. 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.

43. The nurse recognizes that an example of a cognitive outcome is:

The client identifies three foods high in potassium by August 8.

20. 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.

32. When establishing client outcomes with the client, what is the qualifier in the outcome?

The outcome parameter

36. The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is:

a clinical pathway.

33. 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

1. Which is most important for the nurse to include in a client's plan of care?

Nursing interventions

45. 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?

Updating the diet orders in the client's plan of care

35. 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.

-Are the interventions realistic and do they require resources available to the nurse? -Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background? -Are the interventions compatible with other planned therapies? Are the interventions evidence-based?

13. A nurse is caring for a client admitted for bowel obstruction, which now has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply.

-Begin feedings with clear broth. -Consult with a dietitian regarding appropriate foods. -Auscultate for bowel sounds.

40. A nurse is developing short-term outcomes for a client with a nursing diagnosis of "Deficient Knowledge related to insulin self-administration as evidenced by statements of therapy being new and never having done it before." When writing the outcomes, which verbs would the nurse use to achieve a psychomotor change in behavior? Select all that apply.

-Demonstrate -Choose

37. 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.

-Impaired Swallowing -Fluid Volume Deficit -Risk for Impaired Skin Integrity -Altered Body Image

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

-Nursing diagnoses -Client goals -Nursing interventions

18. Which are characteristics of appropriate client outcome statements? Select all that apply.

-Specific -Realistic -Measurable

6. What behaviors reflect planning? Select all that apply.

-The nurse considers the developmental level of the client when selecting education materials. -The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. -The nurse decides to assist the client with ambulation in the hallway twice per shift.

34. Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?

Altered Gas Exchange

29. A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem?

Client will not leave the premises without a caregiver.

41. Which action should the nurse perform during the planning phase of the nursing process?

Identify measurable goals or outcomes.

9. A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client.

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

Intervention.

15. 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?

Narcotic analgesic to treat pain

14. 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?

Outcome

17. 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.

2. 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.

22. The nurse recognizes that an example of a cognitive outcome is:

The client identifies three foods high in potassium by August 8.

38. A client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a non blanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take?

The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour.

42. The nurse has established client outcomes and outcome criteria. What should the nurse do next?

Write a client plan of care

16.The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.