FN - Unit 2 - Chapter 17: Outcome Identification and Planning

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? Maintenance Surveillance Psychomotor Psychosocial

Psychomotor Psychomotor interventions include activities such as positioning, inserting, and applying. A psychosocial intervention focuses on supporting, exploring, and encouraging. Maintenance and surveillance are monitoring interventions.

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 selected based on the etiology in the nursing diagnosis and must be compatible with other therapies planned for the client." "The client's developmental level, values, beliefs, and cultural and psychosocial background should be considered when selecting nursing interventions." "Nursing interventions should be consistent with standards of nursing care and research findings." "Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

"Nursing interventions are pretty much the same for clients that have the same medical diagnosis." Nursing interventions should be based on the etiology in the nursing diagnosis, be compatible with other planned therapies, be consistent with standards of care and research, and individualized for the client.

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 A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia Standardized care plans are most appropriate for clients who are experiencing a common and specific health problem, such as pneumonia. Clients with multiple pathologies or symptoms of unknown etiology are unlikely to have their unique needs reflected in a standardized care plan.

A nurse is developing a client's plan of care. As part of planning interventions, the nurse incorporates a set of steps to follow as a means for decision making for care. Which structured methodology is the nurse including in the plan? Procedure Standard of care Algorithm Clinical practice guideline

Algorithm An algorithm is a set of steps that approximates the decision process of an expert clinician and is used to make a decision; these clinical rules are typically embedded in a branching flow chart. A procedure is a set of "how-to" action steps for performing a clinical activity or task. A standard of care is a description of an acceptable level of client care or professional practice. A clinical practice guideline is a statement or series of statements outlining appropriate practice for a clinical condition or procedure.

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. Allow the client to order favorite foods from the hospital menu. Auscultate for bowel sounds. Begin feedings with clear broth. Consult with a dietitian regarding appropriate foods.

Auscultate for bowel sounds. Begin feedings with clear broth. Consult with a dietitian regarding appropriate foods. Feedings should begin slowly with clear liquids as the first food. Immediately resuming a standard diet after a period of having nothing by mouth is likely to result in gastrointestinal distress. It is appropriate for the nurse to monitor bowel sounds and to consult with the dietician.

Which client outcome requires modification? Client will correctly self-administer subcutaneous insulin before discharge. By the end of instruction, client will know how to perform dressing changes. Client will demonstrate safe transfers from bed to chair within 24 hours. Within 2 days, client will describe two responses to firing of the internal defibrillator.

By the end of instruction, client will know how to perform dressing changes. Outcomes should be specific, measurable, attainable, realistic, and timebound. Words such as "know" and "understand" should be avoided because they are too general to be easily measured. Other common errors to avoid are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, and using verbs that are not observable. The answer option related to the client performing dressing changes includes the verb "know," which is not an observable action. All of the other answer options meet the criteria above.

Which elements are important to incorporate into a client's plan of care? Select all that apply. Client participation Care that is realistic and measurable Involvement of support people Standardized care

Client participation Care that is realistic and measurable Involvement of support people The goal of outcome identification is to provide individualized care, not standardized care. Each of the three correct responses meets this criterion.

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client? Comfort the client and family. Provide more information about diabetes. Test the client's blood glucose levels. Ask the client whether anyone else in the client's family also has diabetes.

Comfort the client and family. Comforting skills are nursing interventions that provide stability and security during a health-related crisis. It is appropriate for the nurse to comfort a client who has recently been diagnosed with diabetes and the client's family. Providing more information about diabetes, testing the client's blood glucose levels, and asking the client whether anyone else in the client's family has diabetes are examples of communication, teaching, and assessment skills and would not address the client's need for security.

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 Seeking input from the client regarding preferences for a snack Providing the mother the phone number for the Poison Control Center Assisting the client to validate feelings regarding treatment options

Cutting up food and opening drink containers for the client According to Maslow's Hierarchy of Needs, physiologic needs are essential to maintain life. These needs include oxygen, water, food, temperature, elimination, sexuality, physical activity, and rest. Cutting up food and opening drink containers for the client would meet the most basic need for food. The nurse is meeting safety needs by providing a mother with the phone number for the Poison Control Center. The nurse seeking input from the client regarding preferences for a snack is showing respect to the individual and meeting self-esteem needs. When assisting the client to validate feelings regarding treatment options, the nurse is acknowledging the uniqueness of the client and respecting the client's knowledge and feelings in solving problems to attain self-actualization.

A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking." What is the priority nursing diagnosis? Impaired Walking Activity Intolerance Deficient Diversional Activity Disturbed Body Image

Deficient Diversional Activity Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, or circulation. Safety issues, such as threats of self-harm, are also highest priority. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. In this case, the priority focus is diversional activity since the client must allow healing before walking and beginning physical therapy. While the other options are implied in the case, there is no direct evidence that they are higher priority than diversional activity.

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

Demonstrate State Explain When writing client outcomes, the nurse should use action verbs so that the client's behavior can be evaluated. Verbs such as demonstrate, state, and explain are appropriate action verbs. Understand and know are difficult to evaluate because they lack a behavioral component.

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.

Encourage hourly use of the incentive spirometer. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions.

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

Impaired Swallowing Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image Maslow's hierarchy of needs can help nurses prioritize the sequence for addressing client needs. Basic physiologic needs, such as airway, breathing, and circulation, should be resolved before potential needs, or higher level needs such as self-esteem. Impaired swallowing is highest priority because the client may have difficulty ingesting both nutrition and fluids, and also has the potential for aspiration. A current need, such as fluid volume deficit, rates higher priority than a potential problem, risk for impaired skin integrity, or one higher on Maslow's scale, altered body image.

Which provides the best framework for prioritizing client problems? Availability of hospital resources Family member statements Maslow's hierarchy of needs Nursing skill

Maslow's hierarchy of needs Maslow's hierarchy of needs provides a useful framework for prioritizing problems, with the first level given to meeting the physical needs of the client. The focus for the client assessment is on the client and not the availability of hospital resources, family member statements, and nursing skills; these do not provide an appropriate framework for prioritization of client problems. Family member statements can be included later, after the assessment of the client is performed.

Which are characteristics of appropriate client outcome statements? Select all that apply. Measurable Realistic Specific Short-term Broad in scope

Measurable Realistic Specific Expected client outcomes should be specific (not broad in scope), measurable, realistic statements of goal attainment. They may restate the goal, but they also present information that will guide the evaluation phase of the nursing process. To be specific and measurable, certain requirements must be met when writing outcomes. Outcomes answer the questions who, what actions, under what circumstances, how well, and when. Outcomes may be short- or long-term and include a range of expectations about what the client's condition will be after nursing intervention.

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. Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a health care provider's order. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. They are not performed to diagnose any problem, medical or otherwise, but to help prevent or resolve a problem identified in a nursing diagnosis and thereby to achieve the related expected client outcome.

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 Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning.

A nurse is reviewing the plan of care for a client and notes: "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." The nurse should identify this statement as an example which element of nursing practice? Nursing diagnosis Outcome Intervention Evaluation

Outcome This statement is an example of an expected client outcome. Outcomes answer the questions who (the client), what actions (verbalizes), under what circumstances (to the staff), how well (accurately), and when (before discharge). A nursing diagnosis, which identifies a client health problem, would include a diagnostic label, related factors, and defining characteristics. An intervention would reflect an action or treatment the nurse performs to promote client outcomes. An evaluation is not a statement but rather a process of assessing the client's response to nursing interventions.

Which phase of the nursing process most involves establishing priorities? Assessment Diagnosis Outcome identification and planning Implementation

Outcome identification and planning During outcome identification and planning, the nurse establishes priorities as well as client goals and outcomes. During this phase, the nurse also plans nursing interventions and writes the plan of care. Assessment involves data collection; diagnosis involves identifying client problems. Implementation involves putting the plan of care into action.

Which phase of the nursing process most involves establishing priorities? Assessment Diagnosis Outcome identification and planning Implementation

Outcome identification and planning During outcome identification and planning, the nurse establishes priorities as well as client goals and outcomes. During this phase, the nurse also plans nursing interventions and writes the plan of care. Assessment involves data collection; diagnosis involves identifying client problems. Implementation involves putting the plan of care into action.

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. Elevate the injured arm on a pillow. Apply ice to the casted extremity. Give prescribed pain meds.

Perform hourly neurovascular assessment. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. This client exhibited a possible complication of impaired peripheral tissue perfusion. The nurse modifies the plan of care to increase the frequency of assessment in order to identify further complication. While the other nursing interventions are routine comfort measures used following injury, they are not sufficient to treat the complication.

Which action should the nurse perform during the planning step of the nursing process? Interprets and analyzes the client data Establishes a database for the client Identifies client strengths and weaknesses Selects nursing measures, including client education

Selects nursing measures, including client education During the planning phase of the nursing process, the nurse establishes priorities, identifies and writes expected client outcomes, selects evidence-based nursing interventions, and communicates the plan of nursing care. The nurse interprets and analyzes the data and identifies client strengths and weaknesses during the diagnosis phase of the nursing process. Establishment of a database occurs during the assessment phase.

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. A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nurse-initiated interventions, such as teaching, do not require a health care provider's order. A health care provider's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

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. Cognitive outcomes describe increases in client knowledge or intellectual behaviors, such as identifying three foods high in potassium. Demonstrating self-catheterization and measuring the radial pulse are examples of psychomotor outcomes, whereby new skills are achieved. Affective outcomes describe changes in client values, beliefs, and attitudes, such as increased confidence.

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. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable. The verbs in the distractors are all measurable. The correct response has a goal that the nurse will be unable to measure.

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: a guideline. an algorithm. a critical pathway. an order set.

a guideline. A guideline is defined as a broad, research-based practice recommendation that may or may not have been tested in clinical practice. An algorithm has intense specificity and provides no provider flexibility; it is used to manage high-risk groups within a cohort. A critical pathway represents a minimal practice standard for a specific client population. An order set includes preprinted provider orders used to expedite the order process.

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually does not contain documented scientific rationales. does not contain abbreviated nursing diagnoses. separates goal statements from the plan of care. separates outcome criteria from the plan of care.

does not contain documented scientific rationales. In clinical settings, nurses may use rationales to illustrate research findings or support controversial approaches to problems. These rationales are not typically included in the clinical nursing care plan. The process of developing both clinical and instructional nursing care plans would follow similar procedures in addressing the other aspects of the nursing care planning process.

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

intervention. A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance client goals and outcomes. Nursing diagnoses are statements of the client's actual or potential health problems that the nurse is seeking to address through interventions and are the overarching driver of goal-setting, care planning, and interventions. Evaluation, the final phase of the nursing process, involves assessing the client's response to interventions on an ongoing basis and making any necessary adjustments and changes to the nursing care plan.

The nurse should derive the outcomes for a client's care plan from: the problem statement of the nursing diagnosis. the defining characteristics in the nursing diagnosis statement. assessment data gleaned from the health care provider's progress notes. assessment data provided by the multidisciplinary team.

the problem statement of the nursing diagnosis. Outcomes are derived from the problem statement of the nursing diagnosis. Remember that the nursing process is based on independent nursing actions. The nurse gathers assessment data from the client's health history and the nurse's comprehensive assessment of the client (not from the health care provider's progress notes or a multidisciplinary team) during the assessment phase of the nursing process, which immediately precedes the diagnosis phase. Outcomes are not derived directly from assessment data but rather from the problem statement of the nursing diagnosis, which based on analysis and interpretation of the assessment data. The defining characteristics of the nursing diagnosis provide the evidence or exemplars on which the nursing diagnosis is based; outcomes are not based on these.

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority? Client will discuss drinking habits in therapy sessions the day after admission. By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms Client will commit to completing a 12-step program within 24 hours of admission. Within 3 days, client will be discharged.

By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms Safety is a top client priority. About half of all clients with alcohol addiction may develop alcohol withdrawal, which can lead to delirium tremens (DTs) with an estimated 15% fatality rate. The client who can recognize the need for tranquilizers can be treated to avoid DTs. It is unrealistic to expect the client to begin a 12-step program only 48 hours after being admitted in withdrawal. Similarly, starting therapy the day after admission would be premature. There is no way of knowing if a 3-day admission is sufficient for the client's needs.

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 Failing to update the written plan of care Beginning the plan without family to help Stating outcomes too broadly

Choosing actions that do not solve the problem Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. In this case, ALS is a progressive degenerative neuromuscular disorder. It is unrealistic to expect the client to regain abilities that are lost.

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. Client will wear an ID bracelet with name and contact information. Client will identify landmarks that indicate location of home. Client will consistently return to the police station when lost.

Client will not leave the premises without a caregiver. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with dementia, the most direct resolution of wandering is for the client to remain in the presence of someone who can prevent wandering.

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. Client will avoid straws and drink thickened liquids. Client will sit in chair for all meals and snacks. Client will chew food well and use a tongue sweep.

Client will use chin tuck and double swallow for each bite. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these actions will improve oral intake by the client with dysphagia, the most effective is a chin tuck and double swallow. These actions reduce the risk of aspiration and aid the movement of food down the esophagus.

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

Define Verbalize The verb should indicate an observable action that the client is to perform, such as define, prepare, identify, design, list, verbalize, describe, choose, explain, select, apply, and demonstrate. The verbs know, hear, and feel indicate internal states or senses, which are not observable or actions.

Which actions should the nurse perform during the planning step of the nursing process? Select all that apply. Establishing priorities Collecting and interpreting client data Identifying expected client outcomes Selecting evidence-based nursing interventions Evaluating client responses to interventions Communicating the plan of nursing care

Establishing priorities Identifying expected client outcomes Selecting evidence-based nursing interventions Communicating the plan of nursing care During the planning phase of the nursing process the nurse establishes priorities, identifies and writes expected client outcomes, selects evidence-based nursing interventions, and communicates the plan of nursing care. Collecting and interpreting data describes the assessment and diagnosis phases of the nursing process. Evaluating client responses to interventions occurs during the evaluation phase.

Which is the primary benefit of outcome identification? It allows the nurse to evaluate the outcomes. It promotes the client being an active participant in care. It promotes an effective diagnostic process. It allows for the identification of proper diagnoses.

It promotes the client being an active participant in care. Outcome identification serves the purpose of promoting client participation. Evaluation takes place after the nurse has identified outcomes and performed interventions and thus is not the primary benefit of outcome identification. Nursing diagnosis occurs before outcome identification and thus is not its primary benefit.

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 Discharge planning should begin when a client is admitted for treatment. All the other times listed are too late and are not consistent with a client who is able to understand the process of the hospitalization.

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 An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the expected client outcome. A broad view of evaluation in health care includes three approaches, directed toward structure, process, and outcome, depending on the focus of evaluation and the criteria or standards being used. Process/implementation evaluation determines whether program activities have been implemented as intended. Cost-effectiveness evaluation compares the relative costs to the outcomes (effects) of two or more courses of action. Structure evaluation assesses the effectiveness of various health care structures.

What are specific measurable and realistic statements of goal attainment? Nursing diagnoses Nursing interventions Evaluations Outcomes

Outcomes Expected client outcomes are specific, measurable, realistic statements of a client's goal attainment. Nursing diagnoses, interventions, and evaluation do not apply to outcomes or goals of nursing care. Nursing diagnoses are statements describing a client's actual or potential health problems that the nurse can treat independently using nursing interventions. Nursing interventions are the actions nurses take to treat the client's health problems. Evaluations are assessments of the effectiveness of interventions in resolving clients' health problems.

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. Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. "Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse" has all of these characteristics. "The nurse will help the client ambulate the length of the hallway once a day" is not specific in whether assistance is required, is not timebound, and is not client-centered, in that the nurse is the subject of the sentence, not the client. "Offer to help the client walk the length of the hallway each day" is a nursing intervention, not a client outcome. "The client will become mobile within a 24-hour period" is not specific or measurable.

The nurse developed a plan for a client and has been working with the client for several months. The client reports feeling better due to an ability now to participate actively in water aerobics. What type of outcome is this? Affective Psychomotor Physiologic Cognitive

Psychomotor Psychomotor outcomes describe the client's achievement of new skills. An affective outcome involves changes in the client's values, beliefs, and attitude, such as feeling an inner strength. Cognitive outcomes demonstrate increases in client knowledge. Physiologic outcomes are physical changes in the client.

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? Adjust expected outcome to have client ambulate a shorter distance. Return the client to bed and provide pain relief measures. Ask the client to describe a personal walking goal. Review evidence-based interventions for the client's pain.

Return the client to bed and provide pain relief measures. While all of these interventions could be used to meet the client's outcomes, the most immediate need is for pain relief. Highest priority nursing diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, or circulation. Safety issues, such as threats of self-harm, are also highest priority. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. This client has a medium level diagnosis because acute pain is interfering with function.

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 Outcome criteria Goals Nursing orders

Scientific rationales With a student care plan, interventions must be accompanied by the scientific rationales as to the justification or reason for carrying out the interventions. Outcome criteria are specific, measurable, realistic statements that can be evaluated to judge goal attainment. Goals are broad statements that reflect resolution or correction of the identified client problem. Nursing orders is a term that may be used instead of nursing interventions.

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. Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement.

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. Outcomes are client-centered, use action verbs, identify measurable performance criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted. Defining characteristics are a component of the nursing diagnosis, not a client outcome. Because outcomes are client-centered, they describe what the client will do, not what the nurse will do.

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "The client will know how to self-administer prescribed bronchodilators using a nebulizer by 09/09/2020." Why is this outcome inadequate? The outcome is not observable or measurable. The outcome is not related to an independent nursing action. The outcome does not specify the conditions in which it will be achieved. The statement expresses a client outcome as a nursing intervention.

The outcome is not observable or measurable. The verb in this outcome, "know," is not directly measurable or observable. The verb "demonstrate" would be more appropriate. Educating a client on how to use a nebulizer is an independent nursing action. The outcome is not expressed as a nursing intervention and conditions are not likely necessary for this outcome.

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. One of the most important considerations in writing outcomes is to encourage clients and families to be as involved in goal development as their abilities and interests permit. 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 and thus would not require input from the health care provider, the nurse manager, or multidisciplinary team.

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

physiological. The NIC is a comprehensive, evidence-based, standardized system for classifying nursing interventions. NIC groups interventions within seven domains, which, in order from the simplest to the most complex, are: Physiological: Basic; Physiological: Complex; Behavioral; Safety; Family; Health System; and Community.

Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal? Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. Assist the client to put on the clothing that goes over the operated leg. Tell the client's family to bring in clothes a size larger to make dressing easier. Arrange for the social worker to schedule home health care with discharge planning.

Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. Nursing interventions designed to promote client independence will implement methods for the client to perform a skill without help. Assistive devices for eating, bathing, dressing, and ambulation are common tools to develop client independence. The other options do not directly promote independent activity.

A client had a cholecystectomy 2 hours previously and is waking up from anesthesia. The client asks, "how long it will be before I can go home?" The nurse responds that most clients are discharged within 2 days. The nurse's answer is most likely based on which piece of information? The individualized plan of care The scientific rationale The agency's critical path The client outcomes

The agency's critical path The critical path is based on large bodies of research and provides information on a client's expected course for a specific treatment or illness. Deviations from the critical path are documented in the individualized plan of care. Because the nurse refers to a standard process, it is clear that it is not based on the client's individualized plan of care, which applies only to that client. Although the critical path itself is based on scientific rationale, the nurse in this case is not citing that rationale directly but rather the critical path. The client expected outcomes would be the goals that the nurse has set for this particular client, which would not pertain to the experience of "most clients."

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. The client will express an understanding of strategies for managing fatigue and shortness of breath. The client will ambulate 100 feet without supplementary oxygen or mobility aids. The client will demonstrate the correct use of a metered-dose inhaler.

The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. Long-term outcomes require a longer period (usually more than a week) to be achieved than do short-term outcomes. They also may be used as discharge goals, in which case they are more broadly written and communicate to the entire nursing team the desired end results of nursing care for a particular client. Resumption of ADLs in the home setting is characteristic of a long-term outcome. Explaining energy-conservation techniques, mobilizing in the hospital, and demonstrating correct medication administration are short-term outcomes that may be accomplished prior to discharge.

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? "Client will learn to cope more effectively." "Client will list positive coping strategies and use them." "Client will identify one coping strategy to try by end of week." "Client tries using relaxation as a means to cope."

"Client will identify one coping strategy to try by end of week." An appropriate outcome includes the client, an action verb, the circumstances by which the outcome is to be achieved, the performance criteria, and time frame. Identifying one coping strategy to try by the end of the week meets these criteria. The statement about the client learning to cope more effectively is not measurable. The statement about listing positive coping strategies and using them includes more than one behavior to evaluate, making it difficult to evaluate achievement. The statement about using relaxation is vague and not really measurable.

The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) 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 take the medications until the inflammation goes away." "I will take my medications on an empty stomach for maximum effect." "I should increase water intake if I have dark bowel movements." "I should call my health care provider if I have a sore that won't heal."

"I should call my health care provider if I have a sore that won't heal." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration, storage, and conditions that require contact with the health care provider.

The expected outcome for a client with a new diagnosis of osteoporosis is "Client will implement actions to promote safety and bone strength." Which statement by the client is the best indicator that the outcome expectations have been met? "I take extra calcium to make my bones stronger." "I removed scatter rugs from my home." "I walk daily wearing low-heeled shoes." "I turn on lights at night so I won't fall."

"I walk daily wearing low-heeled shoes." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new diagnosis must learn appropriate actions for care. With osteoporosis the most important means to prevent further bone loss is weight-bearing activity, such as walking. While each option is appropriate for a client with osteoporosis, only one includes both components of the outcome. Activities that prevent falls, such as wearing low-heeled tie shoes, turning on lights, and removing scatter rugs, are important for safety.

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 take insulin until my blood sugar levels are normal." "I will take my medications between meals for maximum effect." "I will mix insulin glargine with insulin lispro at bedtime." "I will test my glucose level before meals and use sliding scale insulin."

"I will test my glucose level before meals and use sliding scale insulin." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration and storage and conditions that require contact with the health care provider. Diabetes mellitus is a chronic disease, so the client who takes insulin should not expect to ever achieve a normal blood glucose level without taking insulin. The client should test blood glucose level before, not between, meals. Mixing different types of insulin is not necessary.

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." In the planning stage of the nursing process, the nurse must focus on the client's interests and preferences, keep an open mind, and include interventions that are supported by research. 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. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.

A nurse identifies the following nursing diagnosis for a client with an infected leg ulcer: "Deficient Knowledge related to diminished peripheral circulation and wound care as evidenced by recurrent infected leg ulcer." Which statement would the nurse identify as addressing a cognitive outcome? "The client states the reason for wound care measures." "The client demonstrates how to irrigate leg wound." "Client chooses correct size of dressing to cover the wound." "Client verbalizes being motivated to continue follow-up to prevent recurrence."

"The client states the reason for wound care measures." Cognitive outcomes describe increases in client knowledge or intellectual behaviors, such as stating the reason for wound care measures. Psychomotor outcomes describe the client's achievement of new skills, such as demonstrating irrigation or choosing the appropriate wound dressing. Affective outcomes describe changes in client values, beliefs, and attitudes, such as verbalizing motivation to follow-up for prevention.

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? A plan designed to support the client physically A plan derived from a consensus of opinions of all staff members A plan with problems that are easily solved A plan made in conjunction with the hospital's ethics committee

A plan designed to support the client physically An unconscious client who is unable to provide input into outcome identification depends on the nurse to make informed choices to support the client physically. This care plan would treat any life-threatening situations and act to prevent the development of unhealthy physical consequences. The nurse is in the best position to determine client needs and would not seek the opinion of all staff members or the ethics committee. The care plan would deal with all problems, not just those that are easily solved.

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 An order set Guidelines An algorithm

A standardized care plan Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. An algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions. A guideline is a statement by which to determine a course of action. An order set is a predetermined set of orders by a prescriber that dictates care of the client.

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. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates risk for self-harm, not resolution of the depression. The nurse will perform additional assessment and add the new nursing diagnosis to the care plan. Changing the care plan to incorporate this new data makes it the most effective for treating the client. Telling another nurse could assist in treatment, but is less formal and less effective, because the entire team needs access to this information. While group therapy may provide help, it does not address the client's current mental health status related to self-harm.

The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply. Demonstrate the correct use of crutches to the client prior to discharge. The client will know how to dress the wound after receiving a demonstration. After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn. By 4/5/20, the client will demonstrate how to care for a colostomy. The client will list the dangers of smoking and quit. After counseling, the client will describe two coping measures to deal with stress.

After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn. By 4/5/20, the client will demonstrate how to care for a colostomy. After counseling, the client will describe two coping measures to deal with stress. Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. The above goals that have these characteristics are: "After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn"; "By 4/5/20, the client will demonstrate how to care for a colostomy"; and "After counseling, the client will describe two coping measures to deal with stress." "Demonstrate the correct use of crutches to the client prior to discharge" is a nursing intervention, not an outcome. "The client will know how to dress the wound after receiving a demonstration" is not measurable. The client demonstrating a technique is measurable, but "will know" is not measurable. "The client will list the dangers of smoking and quit" is not timebound.

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? Interrupted Breastfeeding Ineffective Thermoregulation Altered Gas Exchange Impaired Parenting

Altered Gas Exchange Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, circulation, or safety issues such as threats of self-harm. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. Lack of surfactant interferes with lung expansion and can reduce oxygenation in premature infants. Breastfeeding and temperature regulation are of lower importance than oxygenation. Parenting skills may be promoted when parents visit high-risk infants in the nursery.

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. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 and 120/80 mm Hg. The other options do not directly indicate successful control of hypertension.

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. Client will increase protein intake in small frequent meals. Client will use oxygen by nasal cannula when short of breath. Client will consistently perform pulmonary exercises.

Client will alternate rest periods with exercise throughout the day. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will promote health in a client with COPD, the most direct resolution of activity intolerance is for the client to pace activities by alternating rest with exercise throughout the day.

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. Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy meets all of these criteria. "After attending sibling classes, client will be happy about a new infant and demonstrate feeding" is incorrect because it includes more than one client behavior, one of which is not observable or measurable ("be happy"), does not include performance criteria related to how well the client is to demonstrate feeding, and has a vague time frame ("after attending sibling classes"). "By the next clinic visit, client will report taking antihypertensive medication" lacks specificity regarding how often the client should take the medication. "Client will perform complete ostomy care while bathing on the second postoperative day" is likely not attainable within the time frame specified and lacks specificity regarding care the client will provide, making it difficult for the nurse to measure the client's success.

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. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. 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.

Which is an appropriate expected outcome for a client? By the next clinic visit, client will report taking antidepressant medication. After attending diabetes education classes, client will understand diet modifications. Client will independently follow transplant medication schedule 1 week after surgery. Client will perform complete PICC line care within 24 hours of insertion.

Client will independently follow transplant medication schedule 1 week after surgery. Outcomes should be specific, measurable, attainable, realistic, and timebound. Expecting a transplant recipient to follow the medication schedule after surgery is reasonable and meets all the characteristics of an outcome. The other options are not complete. Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable, such as "know" and "understand."

Which outcome is sufficiently measurable? Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020. Client will progress from clear fluid diet to full fluid diet without experiencing nausea. Increase client's diet from clear fluids to full fluids by 12/15/2020. Client will maintain adequate intake with no reports of nausea by 12/15/2020.

Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020. A fully measurable outcome should include a subject, verb, conditions, performance criteria, and target time (though not every outcome requires each parameter). Only the outcome "Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020" includes all appropriate components. The outcome "Client will progress from clear fluid diet to full fluid diet without experiencing nausea" lacks a target time. The outcome "Increase client's diet from clear fluids to full fluids by 12/15/2016" expresses the outcome as a nursing intervention. The outcome "Client will maintain adequate intake with no reports of nausea by 12/15/2016" does not define the performance criteria sufficiently, because "adequate intake" is an imprecise term.

Which guideline should the nurse follow when including interventions in a plan of care? Make sure the nursing interventions are unrelated to the original outcomes. Date the nursing interventions when written and when the plan of care is reviewed. Make sure the attending health care provider approves of and signs the nursing interventions. Make sure each nursing intervention does not describe the action the nurse should perform.

Date the nursing interventions when written and when the plan of care is reviewed. Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The health care provider does not approve and sign the interventions, because they are nursing interventions.

A nurse administers colchicine according to the standardized plan of care for a client admitted with acute gouty arthritis of the right great toe. Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention? Uric acid level decreases. Client walks to the bathroom. Foot remains red and swollen. Client reports diarrhea.

Foot remains red and swollen. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for gouty arthritis is reduction in pain. Pain reduction may occur before reduction of redness and swelling is visible. Diarrhea is a possible toxic effect of colchicine.

Which action should the nurse perform during the planning phase of the nursing process? Assess the client's overall health. Identify measurable goals or outcomes. Analyze the client's response to medicines. Identify the client's health-related problems.

Identify measurable goals or outcomes. In the planning phase of the nursing process, the nurse identifies measurable goals or outcomes, prioritizes nursing diagnoses and collaborative problems, selects appropriate interventions, and documents the plan of care. The nurse assesses the client's overall health during the assessment step of the nursing process, not during the planning step. The nurse identifies the client's health-related problems during diagnosis and analyzes the client's response to medicines during the evaluation process.

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 not carry out health care provider-initiated interventions. A health care provider-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the health care provider and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding health care providers to implement orders, nurses may request a health care provider to implement an order or question an existing order by the health care provider if the nurse believes it is in the client's best interests.

A computerized information system developed to classify client outcomes is the: NANDA-International list Nursing Outcome Classification system International Classification of Diseases Clinical Care Classification System

Nursing Outcome Classification system The Nursing Outcome Classification system organizes outcomes according to categories, classes, labels, indicators, and measurement activities. The remaining options do not classify client outcomes. NANDA-International is an organization that develops standardized terminology for nursing diagnosis to ensure client safety and improve client outcomes. The International Classification of Diseases is a classification system for classifying diseases according to diagnosis codes. The Clinical Care Classification System is a standardized system of codes used to label discrete components of nursing practice.

Which elements are common to any type of plan of care? Select all that apply. Nursing diagnoses Client goals Nursing interventions Past medical history Medical diagnoses

Nursing diagnoses Client goals Nursing interventions Regardless of type, the plan of care usually contains three key elements: the nursing diagnosis (client problem), client goals, and nursing interventions (nursing orders, nursing actions). Nursing plans of care need not necessarily include the client's past medical history or medical diagnoses.

Which statement on a plan of care should a nurse identify as a nursing intervention? The client self-administered insulin correctly following education. The client will correctly demonstrate deep-breathing exercises after education. Perform range-of-motion exercises to all of the client's joints each morning. Readiness for Enhanced Communication

Perform range-of-motion exercises to all of the client's joints each morning. A nursing intervention is a treatment that the nurse performs to enhance client outcomes, such as "Perform range-of-motion exercises to all of the client's joints each morning." "The client self-administered insulin correctly following education" is an evaluative statement that the nurse might document to indicate the effectiveness of client education related to insulin self-administration. "The client will correctly demonstrate deep-breathing exercises after education" is an expected client outcome. "Readiness for Enhanced Communication" is a health promotion nursing diagnosis.

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 the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as? Rationale Outcome Nursing intervention Nursing diagnosis

Rationale The nursing rationale is "why" a nursing intervention is to be performed. In this case, the reason for assisting with position changes is to prevent pressure injuries. The nursing diagnosis is the client's health problem that the client outcome and the nursing intervention must address. In this case, the likely nursing diagnosis would be Risk for Impaired Skin Integrity. The client outcome is the goal that the nursing interventions are attempting to achieve. In this case, the client outcome would be something like, "The client will not develop any pressure injuries before discharge." The nursing intervention is an action the nurse takes to address the client's health problem and achieve the client's outcomes. In this case, the nursing intervention is providing assistance with position change every 2 hours.

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. While each option is appropriate, it is crucial to find research to support the plan before establishing priorities. The nurse planning care uses clinical reasoning to set priorities that incorporate standards and agency policies, identify and record expected client outcomes, select evidence-based nursing interventions, and record the plan of care.

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. The nursing interventions written to assist a client to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what assessments need to be made and what nursing interventions, including teaching, counseling, and advocacy, need to be done. They should also include evaluation of the outcome of the intervention. "Start from client's knowledge, teach about diet modifications, and check for learning" provides the most comprehensive intervention for this client, as it includes assessment of the client's current level of knowledge, teaching, and evaluation of the teaching. None of the other answer options includes all three of these elements.

What behaviors reflect planning? Select all that apply. The nurse decides to assist the client with ambulation in the hallway twice per shift. The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. The nurse considers the developmental level of the client when selecting education materials. The nurse assesses the client's usual sleep routine. The nurse assists the client with bathing, grooming, and dressing.

The nurse decides to assist the client with ambulation in the hallway twice per shift. The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. The nurse considers the developmental level of the client when selecting education materials. Planning involves selecting evidence-based nursing interventions that will best address a client's problems as specified in the nursing diagnoses and thereby achieve the client's planned outcomes. Deciding to assist the client with ambulation, seeking input from the client and family on pain management, and considering a client's developmental level when selecting educational materials are all actions involving the nurse selecting interventions to best meet the client's needs. Assessing the client's usual sleep routine is an example of the assessment phase of the nursing process, not the planning phase. Assisting the client with bathing, grooming, and dressing is an example of the implementation phase of the nursing process, not the planning phase.

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? Posting the sign "NPO after midnight" over the bed Updating the diet orders in the client's plan of care Obtaining written consent for the diagnostic procedure Adding the diagnosis "Altered Nutrition, Less Than Required"

Updating the diet orders in the client's plan of care The plan of care communicates three different types of nursing care: care related to meeting basic human needs, care related to nursing diagnoses, and care that must be coordinated with medical and interdisciplinary providers. Nutrition is a basic human need. The temporary need to withhold food and fluid should be documented in the record. The other options are not the best, most direct methods for conveying this information to all who may need it.

Which outcome statements are in the cognitive realm? Select all that apply. Within 1 week after teaching, the client will list three benefits of quitting smoking. By 6/8/20, the client will correctly demonstrate self-injecting insulin. After viewing the film, the client will verbalize four benefits of daily exercise. By 6/8/20, the client will describe a meal plan that is high in fiber. By 6/8/20, the client will correctly demonstrate ambulating with a walker.

Within 1 week after teaching, the client will list three benefits of quitting smoking. After viewing the film, the client will verbalize four benefits of daily exercise. By 6/8/20, the client will describe a meal plan that is high in fiber. Cognitive outcomes describe increases in client knowledge or intellectual behaviors. Listing benefits of quitting smoking, describing meal plans, and verbalizing benefits of exercise demonstrate increased client knowledge. Administering an injection and correctly ambulating with a walker demonstrates a psychomotor outcome.

Which is an example of a psychomotor outcome? Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. The client will verbalize understanding of the need to continue to take medications as prescribed. The client's skin will remain smooth, moist, and without breakdown or ulceration.

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. Outcomes may be categorized according to the type of change they describe for the client. Psychomotor outcomes describe the client's achievement of new physical skills, such as changing an abdominal dressing. Cognitive outcomes describe an increase in the client's knowledge, such as understanding the need to continue to take medications as prescribed. Affective outcomes describe changes in client values, beliefs, and standards, such as decreasing the number of cigarettes one smokes due to adopting a belief that smoking is harmful. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved, such as a client's skin not developing breakdown or ulceration.

The nurse is developing goals for a newly admitted client with visual and auditory hallucinations. Which outcome is the priority for the client? Client will understand that the hallucinations aren't real in therapy sessions before discharge. Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior. Client will verbalize side effects of antipsychotic medications within 24 hours. Within 2 days, client will perform personal hygiene without reminders.

Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior. Outcomes should be specific, measurable, attainable, realistic, and timebound. Words such as "know" and "understand" should be avoided because they are too general to be easily measured. Other common errors to avoid are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, and using verbs that are not observable. Safety is a priority for all clients. Clients with thought and mood disorders may present a risk of harm to self or others because of distorted thinking. Therefore, the ability of the client to mingle with others without violence is the highest priority.

The nurse has established client outcomes and outcome criteria. What should the nurse do next? Establish priorities Write a client plan of care Determine client goals Identify objectives

Write a client plan of care The planning phase involves writing a client's plan of care based on the outcomes identified during outcome identification. Goals, objectives, and outcomes are terms often used interchangeably, because they are statements of expectations. As such, they would be established during outcome identification, after priorities have been identified.

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. an order set. an algorithm. a protocol.

a clinical pathway. A clinical pathway communicates the standardized, interdisciplinary plan of care for a client. Care guidelines and outcomes are specified for each day of the client's hospital stay. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. An order set is a preprinted set of provider orders that expedite the provider order process. A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of clients within the cohort. It has a broader specificity than an algorithm and allows for minimal provider flexibility by way of treatment options.

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. Because a person's condition changes, priorities change. Priorities are based on information collected during reassessment after recovery and assignment to the acute care setting. As the client heals these priorities can shift rapidly. The client's support system would have more of an impact on priorities of care once the client is being discharged to home, not while the client is in the acute care setting immediately after surgery. Both the client's medical orders and the client's nursing priorities change in response to the client's condition, rather than in response to one another. The client's past medical history, which doesn't change, is less likely to affect the nursing priorities of the client after surgery than the client's condition, which does change.

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. Discharge planning begins at the time of admission with the nurse teaching the client and family specific skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse's admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship.

The nurse is caring for a client with urinary retention. The nurse is carrying out the implementation step in the nursing process when taking which action(s)? Select all that apply. inserting a foley catheter providing client education administering medication as prescribed checking bladder volume with a scanner reviewing the client's health history

inserting a foley catheter providing client education administering medication as prescribed Implementation is the fourth step in the nursing process. Implementation means carrying out the plan of care. These are any interventions or actions the nurse takes in response to assessment findings that have led to the plan of care. The nurse implements medical orders as well as nursing orders, which should complement each other. Inserting a foley catheter, administering medication and providing client education are all examples of nursing interventions. Assessment is the first step in the nursing process. It is the systematic collection of facts or data. During the assessment step in the nursing process, the nurse collects information to determine areas of abnormal function, risk factors that contribute to health problems, and client strengths. Scanning the bladder for urine volume and reviewing the client's health history are examples of data collection the nurse undertakes while completing a client assessment.

The primary purpose of developing expected client outcomes is to: document nursing practice. evaluate nursing interventions. focus on health promotion. provide individualized care.

provide individualized care. The primary purpose of outcome identification is to provide individualized care, but other purposes include to promote participation, to provide care plans that are realistic and measurable, and to allow for involvement of support people. Although the nurse should document outcomes, their primary purpose is not related to facilitating documentation. Although client outcomes are used in evaluation of the client's response to nursing interventions, this is not their primary purpose. Client outcomes do not focus solely on health promotion but may identify a wide array of client health problems, including actual, possible, risk, problem-focused, and health promotion.