Chapter 16: Outcome Identification and Planning

What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)? -Nurses do not carry out health care provider-initiated interventions. -Nurses do carry out interventions in response to a health care provider's order. -Nurses are responsible for reminding health care providers to implement orders. -Nurses are not legally responsible for these interventions.

-Nurses do carry out interventions in response to a health care provider's order.

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. Client will eat small meals of bland foods for 3 days. Client will identify the food that caused the condition within 3 hours. Client will maintain adequate hydration within 2 days.

Client will have formed stools within 24 hours. E: While each of these options will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal

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. Expect to modify the plan significantly. Identify the appropriate nursing diagnoses. Include the rationale for the interventions.

Individualize the plan to the client.

Which statement correctly describes a nurse-initiated intervention? Nurse-initiated interventions are derived from the nursing diagnosis. Nurse-initiated interventions require a health care provider's order. Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. Nurse-initiated interventions are actions performed to diagnose a medical problem.

Nurse-initiated interventions are derived from the nursing diagnosis.

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? Consult with another nurse. Seek research about the disorder. Follow institutional guidelines. Set priorities using client care standards.

Seek research about the disorder.

The nurse recognizes that an example of a cognitive outcome is: -The client demonstrates self-catheterization using clean technique by June 3. -The client identifies three foods high in potassium by August 8. -The client accurately measures the radial pulse for 1 minute by February 2. -The client verbalizes increased confidence in testing glucose levels.

The client identifies three foods high in potassium by August 8. E: Cognitive outcomes describe increases in client knowledge or intellectual behaviors

Which outcome for a client with a new colostomy is written correctly? Explain to the client the proper care of the stoma by 3/29/20. The client will know how to care for the stoma by 3/29/20. The client will demonstrate proper care of the stoma by 3/29/20. The client will be able to care for stoma and cope with psychological loss by 3/29/20.

The client will demonstrate proper care of the stoma by 3/29/20.

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: support system. medical orders. past medical history. condition.

condition

Which verbs would be appropriate to use in client outcomes? Select all that apply. Demonstrate Understand State Know Explain

demonstrate explain state E: Understand and know are difficult to evaluate because they lack a behavioral component

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: discharge planning. initial planning. ongoing planning. comprehensive planning.

discharge planning

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 Structure Outcome Cost-effectiveness

outcome

What verbs should the nurse use to write outcomes that are measurable? Select all that apply. Know Define Hear Verbalize Feel

verbalize define

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 infant 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.

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. TAKE ANOTHER QUIZ

Encourage hourly use of the incentive spirometer.

Which is an example of a nurse-initiated intervention? -Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. -Administer oxygen at 4 L/min per nasal cannula. -Administer a 1000-mL soap suds enema. -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. Nursing interventions include teaching

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 not made any error in writing the outcome. The nurse has omitted the time frame. The nurse has omitted the defining characteristics. The outcome should indicate what the nurse will do.

The nurse has omitted the time frame.

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) Subject Conditions Performance criteria

verb (action)

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

intervention

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. E: understand can't be measured

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 reports no headache. Client is drowsy after lunch. Client is normotensive. Client lipids are within range.

client is normotensive

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? "You need to stop smoking for us to effectively combat this disease." "Please tell me your thoughts about treating this diagnosis." "Do you want to be discharged without treatment?" "What are your plans after discharge?"

"Please tell me your thoughts about treating this diagnosis." E: While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful

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. Encourage the client to join a therapy group. Document that the depression has resolved.

Add the nursing diagnosis: Risk for Self-Harm.

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 Once the client has received a discharge order As soon as possible after the client's surgery Once the client is admitted to the nursing unit from postanesthetic recovery

On the client's admission to the hospital

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. -The nurse will help the client ambulate the length of the hallway once a day. -Offer to help the client walk the length of the hallway each day. -The client will become mobile within a 24-hour period.

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

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. -Present the client with videos and books about diet changes that reduce inflammation. -Ask the client's learning style, then teach diet information using that style. -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. E: include assess, teach, and evaluate

A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client? -The client will perform range of motion exercises 3 times per day. -Passive abduction with assistance -The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day. -The client performed active range of motion exercises only twice today but states a goal of 3 times per day tomorrow.

The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day.

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: -identifies the unhealthy response preventing desired change. -identifies factors causing undesirable response and preventing desired change. -suggests client goals to promote desired change. -identifies client strengths.

identifies factors causing undesirable response and preventing desired change.

The nurse recognizes that identifying outcomes/goals must include: involvement of the client and family. input from the health care provider. input from the multidisciplinary team. involvement of the nurse manager and other staff nurses.

involvement of the client and family. E: The more involved they are, the greater the probability that the goals will be achieved. Client-centered care focuses on the client needs and desires

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 Initial Discharge Outcome

ongoing