Chapter 8: outcome identification and planning

The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply.

-Client will increase nutrition, eating 75% of meals. -Client will report pain is controlled at or below 3 of 10. -Client will perform dressing change independently.

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?

Ongoing planning

A nurse has identified on the plan of care for a client a nursing diagnosis of "Anxiety related to concerns about cancer treatment as evidenced by client's statement." One of the interventions that the nurse writes on the plan of care is to encourage the client to verbalize his feelings about the diagnosis and its effect on his quality of life. The nurse has identified which type of nursing intervention?

Psychosocial

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."

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate?

"Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

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?

"Please tell me your thoughts about treating this diagnosis."

As part of an assignment, a nursing student is asked to create a concept map for a client. The student asks the instructor, "Why is this necessary? Isn't the plan of care enough?" Which response by the instructor would be most appropriate?

"The map helps you to think more critically about the relationship between concepts."

Which actions should the nurse perform during the planning step of the nursing process? Select all that apply.

-Establishing priorities -Identifying expected client outcomes -Selecting evidence-based nursing interventions -Communicating the plan of nursing care

For which client would a standardized plan of care most likely be appropriate?

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia

Which is inappropriate to include in an outcome?

A flexible time frame

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

A standardized care plan

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

Altered Gas Exchange

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.

Which group of terms best describes a nurse-initiated intervention?

Autonomous, clinical judgment, client outcomes

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

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.

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem?

Client will alternate rest periods with exercise throughout the day.

Which is an appropriate expected outcome for a client?

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

Which outcome illustrates a common error nurses make when writing client outcomes?

Client will be less anxious and fearful before and after surgery.

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.

Which type of care plan is most likely to enable the nurse to take a holistic view of the client's situation?

Concept map care plan

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.

What should the nurse do to make outcomes more achievable?

Encourage the client and family to be involved in the development of outcomes.

Which is a common error nurses make when writing client outcomes?

Expressing the client outcome as a nursing intervention

What common problem is related to outcome identification and planning?

Failing to involve the client in the planning process

A nurse working in a critical care unit has formulated the following nursing diagnoses for a client. Which nursing diagnosis likely would be the priority?

Impaired Gas Exchange

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.

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

Make recommendations for revising the plan of care.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order.

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

Nursing interventions

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

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.

A nursing student is writing a student care plan for an assigned client. When identifying specific interventions to be used, which aspect would the student need to include with the interventions?

Scientific rationales

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan?

Standardized

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.

Which intervention does the nurse recognize as a collaborative intervention?

Teach the client how to walk with a three-point crutch gait.

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 return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath.

A resident of a long-term care facility refuses to eat until the client has had hair combed and makeup applied. In this case, what client need should have priority?

The need to feel good about oneself

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 omitted the time frame.

What is the primary purpose of the outcome identification and planning step of the nursing process?

To design a plan of care for and with the client

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

Which is an example of a psychomotor outcome?

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

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using:

assessment skills.

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to lunch and successfully drew up and administered the insulin while the nurse observed. How should the nurse follow up this observation?

Record an evaluative statement in the client's plan of care.

A nurse is developing a care plan for a client with a stroke and is including surveillance interventions. What would the nurse most likely include?

monitoring blood pressure

Which are correctly written nursing interventions? Select all that apply.

-Provide 5 to 6 small meals daily. -Reposition the client from side to side every hour around the clock. -Provide opportunities for the client to express concerns and verbalize feelings.

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