Ch 16 Outcome Identification and Planning

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

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

Which is most important for the nurse to include in a client's plan of care? A. Nursing interventions B. Evaluation C. Assessment data D. Medical diagnoses

Correct answer: A, Nursing interventions. Nursing interventions, nursing diagnoses, and client outcomes are important elements of a client's nursing care plan. Evaluation, assessment data, and medical diagnoses are not key elements of the written plan.

When establishing client outcomes with the client, what is the qualifier in the outcome? A. The outcome parameter B. The long-term goal C. The problem statement D. The short-term goal

Correct answer: A, The outcome parameter. The qualifier is a description of the parameter for achieving the outcome. Short-term and long-term goals and the problem statement are distinct from establishing client outcomes.

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 A. separates goal statements from the plan of care. B. does not contain documented scientific rationales. C. separates outcome criteria from the plan of care. D. does not contain abbreviated nursing diagnoses.

Correct answer: B, 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 nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? A. Surveillance B. Supervisory C. Maintenance D. Educational

Correct answer: D, Educational. Demonstrating, teaching, and observing a return demonstration are classified as educational interventions. The remaining terms refer to aspects of monitoring the client and do not apply to this scenario.

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

Correct answer: D, 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.

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

Correct answer: D, 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.

A client has just given birth to a stillborn infant. The client is sobbing and says God is punishing the client for some bad choices in the past. The client reports having always believed in God as a loving and caring presence in life but now feeling that the client's faith is destroyed. Which nursing diagnoses would be appropriate for the nurse to include in this client's care plan? Select all that apply. A. Grieving B. Risk for Suicide C. Defensive Coping D. Spiritual Distress E. Impaired Parenting

Correct answers: A, D - Grieving, Spiritual Distress. The client feels the stillbirth of the child was caused by a vindictive God and is therefore considering leaving the client's religious faith. The client is grieving the loss of the child. There is no evidence of impaired parenting, risk for suicide, or defensive coping.

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? A. Add the nursing diagnosis: Risk for Self-Harm. B. Tell another nurse about this client statement. C. Document that the depression has resolved. D. Encourage the client to join a therapy group.

Correct answer: A, 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.

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer? A. By discharge, the client will perform hand hygiene before and after port care. B. The client will schedule radiation therapy sessions and plan for chemotherapy. C. After attending a cancer support group, the client will report being in a good mood. D. By the next clinic visit, the client will report needing antiemetic medication.

Correct answer: A, By discharge, the client will perform hand hygiene before and after port care. Outcomes should be specific, measurable, attainable, realistic, and timebound. Demonstrating hand hygiene before and after port care is a specific and reasonably attainable goal. The other answer options lack at least one of these criteria. 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 client outcome requires modification? A. By the end of instruction, client will know how to perform dressing changes. B. Within 2 days, client will describe two responses to firing of the internal defibrillator. C. Client will demonstrate safe transfers from bed to chair within 24 hours. D. Client will correctly self-administer subcutaneous insulin before discharge.

Correct answer: A, 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.

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

Correct answer: A, C, D - Auscultate for bowel sounds. Consult with a dietitian regarding appropriate foods. Begin feedings with clear broth. 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.

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? A. Client is normotensive. B. Client is drowsy after lunch. C. Client reports no headache. D. Client lipids are within range.

Correct answer: A, 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.

Which is an appropriate expected outcome for a client? A. Client will ambulate safely with walker in the room within 3 days of physical therapy. B. By the next clinic visit, client will report taking antihypertensive medication. C. After attending sibling classes, client will be happy about a new baby and demonstrate feeding. D. Client will perform complete ostomy care while bathing on the second postoperative day.

Correct answer: A, Client will ambulate safely with walker in the room within 3 days of physical activity. 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 baby 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 nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? A. "Client will identify one coping strategy to try by end of week." B. "Client will list positive coping strategies and use them." C. "Client tries using relaxation as a means to cope." D. "Client will learn to cope more effectively."

Correct answer: A, 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.

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

Correct answer: A, 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? A. Date the nursing interventions when written and when the plan of care is reviewed. B. Make sure each nursing intervention does not describe the action the nurse should perform. C. Make sure the attending physician approves of and signs the nursing interventions. D. Make sure the nursing interventions are unrelated to the original outcomes.

Correct answer: A, 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 physician does not approve and sign the interventions, because they are nursing interventions.

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

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

Correct answer: A, E, F - After sounseling, the client will describe two coping measures to deal with stress. By 4/5/20, the client will demonstrate how to care for a colostomy. After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn. 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.

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

Correct answer: A, Identifies factors causing undesirable response and preventing desired change. The cause of the client health problem is referred to as the etiology. The problem statement of the nursing diagnosis suggests the client goals, and the cause of the problem (etiology) suggests the nursing interventions. Identifying the unhealthy response preventing desired change would occur during the evaluation phase of the nursing process. Client strengths are identified during the nursing diagnosis phase.

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

Correct answer: A, Ineffective Impulse Control. 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; 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. In this case, the lack of impulse control is the greatest risk to the client's well-being. Agitated movement is not a nursing diagnosis.

The nurse recognizes that identifying outcomes/goals must include: A. involvement of the client and family. B. input from the multidisciplinary team. C. input from the physician. D. involvement of the nurse manager and other staff nurses.

Correct answer: A, 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. Patient-centered care focuses on the client needs and desires and thus would not require input from the physician, the nurse manager, or multidisciplinary team.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? A. Nurses do carry out interventions in response to a physician's order. B. Nurses are responsible for reminding physicians to implement orders. C. Nurses do not carry out physician-initiated interventions. D. Nurses are not legally responsible for these interventions.

Correct answer: A, Nurses do carry out interventions in response to a physician's order. A physician-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 physician and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding physicians to implement orders, nurses may request a physician to implement an order or question an existing order by the physician if the nurse believes it is in the client's best interests.

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

Correct answer: A, 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.

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

Correct answer: A, 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 client is on the surgical unit following resection of an intestinal tumor. The client is alert and oriented x3. Based on an assessment of the client, the physician writes a medical order to "ambulate with assistance" in the chart. This will be the client's first time ambulating. Which is the best nursing outcome for this client? A. The client will ambulate with the assistance of a walker without falling within the next 4 hours. B. The client will ambulate to the restroom 3 times this shift. C. The client will ambulate with the assistance of a walker sometime today. D. Physical therapy will be consulted to assist the client with ambulation.

Correct answer: A, The client will ambulate with the assistance of a walker without falling within the next 4 hours. Nursing outcomes should include five components: subject, verb, conditions, performance criteria, and target time. There is only one answer option that includes all five components: the client (subject) will ambulate (verb) with the assistance of a walker (condition) without falling (performance criterion) within the next 4 hours (time frame). The answer option "Physical therapy will be consulted to assist the client with ambulation" does not properly identify the client as the subject or ambulate as the verb (action). The other two answer options lack performance criteria and indicate time frames that are less specific.

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? A. The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. B. The client will demonstrate the correct use of a metered-dose inhaler. C. The client will express an understanding of strategies for managing fatigue and shortness of breath. D. The client will ambulate 100 feet without supplementary oxygen or mobility aids.

Correct answer: A, 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 man runs into the emergency room with an 18-month-old boy in his arms. The man screams, "Help, my son is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis? A. High priority B. Medium priority C. No priority D. Low priority

Correct answer: A, high priority. To develop a prioritized list of nursing diagnoses, the nurse needs guidelines for ranking diagnoses as high, medium, or low priority. High-priority diagnoses pose the greatest threat to the client's well-being (in this case, decreased oxygenation is the greatest threat to well-being and life).

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent? A. Verb (action) B. Subject C. Conditions D. Performance criteria

Correct answer: A, verb (action) The action is one of the essential pieces of an outcome statement. The verb "ambulate" in this case represents the action that the client will perform and that the nurse will monitor and evaluate. The subject refers to the one who performs the action, which is always the client. The conditions are the particular circumstances in or by which the client is to achieve the outcome, such as "with the assistance of a cane" and "during a physical therapy session." The performance criteria are the expected client behaviors or other manifestations described in observable, measurable terms, such as "without incident."

For which client would a standardized plan of care most likely be appropriate? A. A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy B. A client who was admitted for shortness of breath and who has been diagnosed with pneumonia C. A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident D. A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem

Correct answer: B, 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.

Which accurately identify the characteristics of effective client goals represented in the acronym SMART? Select all that apply. A. S = supportive B. T = timebound C. S = specific D. R = realistic E. M = measurable F. A = accurate

Correct answer: B, C, D, E - Timebound, specific, realistic, measurable.

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? A. Ask the client whether anyone else in the client's family also has diabetes. B. Comfort the client and family. C. Test the client's blood glucose levels. D. Provide more information about diabetes.

Correct answer: B, 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.

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? A. Maintenance B. Educational C. Surveillance D. Supervisory

Correct answer: B, Educational Demonstrating, teaching, and observing a return demonstration are classified as educational interventions. The remaining terms refer to aspects of monitoring the client and do not apply to this scenario.

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

Correct answer: B, 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.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? A. Include the rationale for the interventions. B. Individualize the plan to the client. C. Identify the appropriate nursing diagnoses. D. Expect to modify the plan significantly.

Correct answer: B, Individualize the plan to the client. Standardized plans of care are written by a group of nurses who are experts in a given area of practice (e.g., obstetrics, rehabilitation, orthopedics). The plans are written for a client population with a specific medical diagnosis (e.g., total hip replacement, pressure injury, vaginal delivery, coronary artery bypass surgery). These experts identify the most common nursing diagnoses for this client population and write the goals and interventions usually necessary to resolve the problem. Each time a standardized plan of care is used, it must be individualized for a specific client. The danger of a standardized plan of care lies in the fact that it may not fit a specific client. Nurses must make judgments as to the degree to which standardized plans should be modified or whether they should not be used in individual cases. With a standardized plan of care, the most common nursing diagnoses have already been identified. Rationales are typically not included on clinical plans of care.

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? A. Septic workup due to blood pressure and heart rate elevation B. Opioid analgesic to treat pain C. Isolation for suspected respiratory illness D. Acetaminophen to treat pain and fever

Correct answer: B, Opioid analgesic to treat pain. A sickle cell crisis is an extremely painful event. Most clients with sickle cell disease have an individualized opioid plan that will help them to receive opioids in an expedited manner when they present in crisis. The slight elevations in the client's blood pressure and heart rate are likely secondary to pain, not sepsis. There is no evidence of respiratory illness based on the information given. Acetaminophen is not strong enough to treat this client's pain; furthermore, the client does not have a fever.

Which phase of the nursing process most involves establishing priorities? A. Diagnosis B. Outcome identification and planning C. Implementation D. Assessment

Correct answer: B, 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 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? A. Cost-effectiveness B. Outcome C. Process D. Structure

Correct answer: B, 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.

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

Correct answer: B, 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 client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." Which nursing action is the priority? A. Prepare the client for surgery. B. Resolve the client's anxiety. C. Provide preoperative education. D. Evaluate the need for antibiotics.

Correct answer: B, Resolve the client's anxiety. A priority is something that takes precedence in position, deemed the most important among several items. Resolving the client's anxiety is the priority because until it is resolved, the nurse may not be able to effectively provide preoperative education to the client, prepare the client for surgery, or evaluate the need for antibiotics. In fact, the client's anxiety may make it necessary to cancel the surgery altogether. Therefore, to have a successful outcome, the nurse must address the client's psychosocial issues related to anxiety.

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

Correct answer: B, 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.

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? A. Ongoing B. Standardized C. Initial D. Discharge

Correct answer: B, Standardized Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. Initial, ongoing, and discharge are not types of care plans but of planning, in general. Typically, the nurse develops the client's care plan during initial planning and then updates it as needed during ongoing and discharge planning.

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? A. By 08/02, the client will state three therapeutic methods of reducing stress. B. The client will understand the effects of smoking related to heart disease. C. By 8/02, the client will state when to notify the health care provider after discharge D. By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet.

Correct answer: B, 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 client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a nonblanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take? A. The nurse repositions the client to the left side and plans to return in 2 hours to reassess the reddened area on the client's right trochanter. B. The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour. C. The nurse repositions the client to the client's back and documents the condition of the client's skin in the medical record. D. The nurse repositions the client to the client's back and documents the intervention in the client's record.

Correct answer: B, The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hours. An observation of a reddened area on a client's skin that doesn't blanch after pressure is relieved is characteristic of a first-degree pressure injury. This indicates that the current nursing intervention of turning and repositioning the client every 2 hours to prevent impaired skin integrity is inadequate. The client's nursing care plan needs to be revised to reflect the new assessment finding of an actual pressure injury. Additionally, new nursing interventions need to be implemented to turn and reposition the client hourly to relieve the pressure on the trochanter ulcer and prevent the formation of new pressure injuries. Repositioning the client to the client's back, documenting the intervention, reassessing the client's right trochanter in 2 hours, and documenting the condition of the skin in the medical record all fail to update the nursing care plan and revise the interventions to a more frequent turning and repositioning schedule.

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

Correct answer: B, 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.

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

Correct answer: B, 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.

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

Correct answer: B, 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.

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? A. Continue to place the IV. B. Ask Isabel to cough and clear her tracheostomy tube. C. Assess tracheostomy for patency. D. Call respiratory therapy for help.

Correct answer: C, Assess tracheostomy for patency. Airway impairment is considered a life-threatening emergency. This must be assessed and resolved before proceeding with other tasks. There is not enough information given in this scenario to suggest what the next indicated step might be required to clear the ventilator alarm.

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? A. BP is lower than admission B. Client walking gait is steady C. Client gains 1 kg (2.2 lb) in 1 day D. No reports of pain or headache

Correct answer: C, Client gains 1 kg (2.2 lb) in 1 day. A specific, expected client outcome is written for each day in a collaborative plan of care. Expected client outcomes after 24 hours of treatment for hypertension would be for the blood pressure to be reduced toward the normal range, absence of headache, and no orthostatic hypotensive symptoms. However, a side effect of clonidine is weight gain and fluid retention that would require nursing intervention.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? A. Client will maintain adequate hydration within 2 days. B. Client will identify the food that caused the condition within 3 hours. C. Client will have formed stools within 24 hours. D. Client will eat small meals of bland foods for 3 days.

Correct answer: C, 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? A. After attending diabetes education classes, client will understand diet modifications. B. Client will perform complete PICC line care within 24 hours of insertion. C. Client will independently follow transplant medication schedule 1 week after surgery. D. By the next clinic visit, client will report taking antidepressant medication.

Correct answer: C, 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."

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem? A. Client will consistently return to the police station when lost. B. Client will identify landmarks that indicate location of home. C. Client will not leave the premises without a caregiver. D. Client will wear an ID bracelet with name and contact information.

Correct answer: C, 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? A. Client will sit in chair for all meals and snacks. B. Client will chew food well and use a tongue sweep. C. Client will use chin tuck and double swallow for each bite. D. Client will avoid straws and drink thickened liquids.

Correct answer: C, 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.

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: A. support system. B. medical orders. C. condition. D. past medical history.

Correct answer: C, 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.

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? A. Disturbed Body Image B. Activity Intolerance C. Deficient Diversional Activity D. Impaired Walking

Correct answer: C, 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.

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? A. Reassess in 4 hours and document the findings. B. Provide oral pain medication before ambulation. C. Encourage hourly use of the incentive spirometer. D. Promote oral fluid intake between meals.

Correct answer: C, 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.

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

Correct answer: C, 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.

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? A. Once the client has received a discharge order B. Once the client is admitted to the nursing unit from postanesthetic recovery C. On the client's admission to the hospital D. As soon as possible after the client's surgery

Correct answer: C, 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 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? A. Initial planning B. Discharge planning C. Ongoing planning D. Comprehensive planning

Correct answer: C, Ongoing planning. Ongoing planning is carried out by any nurse who interacts with the client. Its chief purpose is to keep the plan up-to-date to facilitate the resolution of health problems, manage risk factors, and promote function. The nurse caring for the client uses new data as they are collected and analyzed to make the plan more specific and accurate and, therefore, more effective. Comprehensive planning involves establishing a plan of care that addresses all aspects of the client's care needs and updating that plan of care as needed until the client is discharged. Comprehensive planning has three phases: Initial planning, ongoing planning, and discharge planning. Initial planning is performed by the nurse with the admission nursing history and the physical assessment and results in the development of a comprehensive plan of care that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. In acute care settings, discharge planning begins when the patient is admitted for treatment—or even before admission. It ensures that the nurse uses teaching and counseling skills effectively to help the client and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors at home competently.

What are specific measurable and realistic statements of goal attainment? A. Nursing interventions B. Evaluations C. Outcomes D. Nursing diagnoses

Correct answer: C, 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 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? A. Give prescribed pain meds. B. Apply ice to the casted extremity. C. Perform hourly neurovascular assessment. D. Elevate the injured arm on a pillow.

Correct answer: C, 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.

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? A. Goals B. Outcome criteria C. Scientific rationales D. Nursing orders

Correct answer: C, 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 action should the nurse perform during the planning step of the nursing process? A. Identifies client strengths and weaknesses B. Establishes a database for the client C. Selects nursing measures, including client education D. Interprets and analyzes the client data

Correct answer: C, 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.

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

Correct answer: C, 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.

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs? A. Assisting the client to validate feelings regarding treatment options B. Seeking input from the client regarding preferences for a snack C. Cutting up food and opening drink containers for the client D. Providing the mother the phone number for the Poison Control Center

Correct answer: C, 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.

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

Correct answer: C, 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 physician'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 assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care? A. A 68-year-old woman with bruises across the chest and lower abdomen who is observed rubbing the bruised area on the lower abdomen and moaning B. An 18-year-old woman sitting up in bed with an egg-size hematoma and a 5-cm laceration on the forehead who is talking rapidly on a cell phone C. A 4-year-old with a deformed left lower leg with equal pedal pulses in both feet and who is crying loudly D. A 45-year-old man with burns to the upper arms and chest and soot on the face who is restless and anxious

Correct answer: D, A 45-year old man with burns to the upper arms and chest and soot on the face who is restless and anxious. Burns to the chest and soot on the client's face indicate that the client inhaled hot smoke and is at risk for ineffective airway clearance due to possible tracheal/bronchial edema. Restlessness and anxiety can indicate hypoxia and are characteristics of the nursing diagnoses of impaired gas exchange and acute confusion. This client should receive the highest priority of care (airway), should be assessed for stridor and respiratory distress, and should have the oxygen saturation level monitored. The other clients listed do not have conditions that are as life-threatening as the man with burns to the arms and chest and soot in the face.

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. a protocol. B. an order set. C. an algorithm. D. a clinical pathway.

Correct answer: D, 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.

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. An algorithm B. Guidelines C. An order set D. A standardized care plan

Correct answer: D, 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.

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

Correct answer: D, 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 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? A. Beginning the plan without family to help B. Failing to update the written plan of care C. Stating outcomes too broadly D. Choosing actions that do not solve the problem

Correct answer: D, 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 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? A. Client will use oxygen by nasal cannula when short of breath. B. Client will consistently perform pulmonary exercises. C. Client will increase protein intake in small frequent meals. D. Client will alternate rest periods with exercise throughout the day.

Correct answer: D, 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.

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? A. Client walks to the bathroom. B. Client reports diarrhea. C. Uric acid level decreases. D. Foot remains red and swollen.

Correct answer: D, 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 statement correctly describes a nurse-initiated intervention? A. Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. B. Nurse-initiated interventions are actions performed to diagnose a medical problem. C. Nurse-initiated interventions require a physician's order. D. Nurse-initiated interventions are derived from the nursing diagnosis.

Correct answer: D, 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 physician'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.

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

Correct answer: D, 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.

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? A. Outcome B. Initial C. Discharge D. Ongoing

Correct answer: D, 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? A. Nursing diagnosis B. Intervention C. Evaluation D. Outcome

Correct answer: D, 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.

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? A. The nurse will help the client ambulate the length of the hallway once a day. B. Offer to help the client walk the length of the hallway each day. C. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. D. The client will become mobile within a 24-hour period.

Correct answer: D, 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.

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

Correct answer: D, 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.

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

Correct answer: D, 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.

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? A. Present the client with videos and books about diet changes that reduce inflammation. B. Ask the client's learning style, then teach diet information using that style. C. Answer the client's questions about diet alterations, and then evaluate understanding. D. Start from client's knowledge, teach about diet modifications, and check for learning.

Correct answer: D, 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.

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? A. Psychosocial B. Coordinating C. Supervisory D. Supportive

Correct answer: D, Supportive. Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems. Coordinating interventions involve many different activities, such acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care.

Which is an example of a nurse-initiated intervention? A. Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. B. Administer a 1000-mL soap suds enema. C. Administer oxygen at 4 L/min per nasal cannula. D. Teach the client how to splint an abdominal incision when coughing and deep breathing.

Correct answer: D, 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 physician's order. A physician's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

When creating a care plan, which is the purpose of identifying the client outcome? A. To provide a basis for the scientific rationale B. To coordinate the nursing intervention C. To evaluate the plan of care developed D. To design a plan of care to address the health problem

Correct answer: D, To design a plan of care to address the health problem. The primary purpose of the outcome identification and planning step of the nursing process is to design a plan of care with and for the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes.

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

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

Correct answer: D, 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.

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

Correct answer: D, 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 has identified short- and long-term goals for a client after surgery to remove a leg tumor. When determining interventions for the goals, which questions are important for the nurse to consider? Select all that apply. A. Are the interventions evidence-based? B. Are the interventions realistic and do they require resources available to the nurse? C. Are the interventions valued by the nursing staff? D. Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background? E. Are the interventions compatible with other planned therapies?

Correct answers: A, B, D, E - Are the interventions evidence based? Are the interventions realistic and do they require resources available to the nurse? Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background? Are the interventions compatible with other planned therapies? When developing nursing interventions, the nurse should be sure that they are appropriate in relation to the nursing diagnosis and related client outcomes, as well as safe and efficient. The interventions should be consistent with evidence-based practice and realistic for delivery of care. They should be valued by the client and family, but not necessarily by the nursing staff. The interventions should be compatible with other planned therapies.

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. A. Client will increase nutrition, eating 75% of meals. B. Client will receive influenza vaccine. C. Client will report pain is controlled at or below 3 of 10. D. Client will maintain oxygen saturation at 81%. E. Client will perform dressing change independently.

Correct answers: A, C, E - Client will increase nutrition, eating 75% of meals. Client will report pain is controlled at or below 3 out of 10. Client will perform dressing change independently. The focus of planning for a client who is expected to make a full recovery is promotion and restoration of health, alleviation of suffering, and prevention of illness, injury, and disease. A client recovering from surgery needs adequate pain control, sufficient nutritional intake for healing, and education in self-care if there are special needs, such as treating a wound, caring for a port, or administering medications. The oxygen saturation level is too low. The influenza vaccine should not be administered to someone with a moderate to severe acute illness.

Which are correctly written nursing interventions? Select all that apply. A. Understand the side effects of furosemide. B. Reposition the client from side to side every hour around the clock. C. Provide 5 to 6 small meals daily. D. Provide opportunities for the client to express concerns and verbalize feelings. E. Know the signs and symptoms of infection.

Correct answers: B, C, D - Reposition the client from side to side every hour around the clock. Provide 5 to 6 small meals daily. Provide opportunities for the client to express concerns and verbalize feelings. Nursing interventions are nurse-centered, action-oriented, and describe specifically what the nurse is doing (how, when, where, how often, how long, or how much). Providing 5 to 6 small meals, repositioning the client, and providing opportunities for expression of concerns and feelings are correctly written interventions. "Understand" and "know" are vague and are not action-oriented; it is unclear who is to perform these actions. Medication side effects and signs/symptoms of infection represent content that the nurse should know and teach to clients.

A nurse is developing the postoperative plan of care for a client admitted with a fractured hip who has undergone surgery to repair it. Which intervention would the nurse identify as a nurse-initiated intervention? Select all that apply. A. Obtain complete blood count and chest x-ray in the morning. B. Administer prescribed opioid analgesic every 4 hours as needed. C. Teach the client how to perform relaxation as a pain relief strategy. D. Assess the client's pain level every 2 hours. E. Turn the client every 2 hours per turning schedule.

Correct answers: C, D, E - Teach the client how to perform relaxation as a pain relief strategy. Assess the client's pain level every 2 hours. Turn the client every 2 hours per turning schedule. Nurse-initiated interventions are autonomous actions based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnoses and projected outcomes. They do not require a physician's order. Rather, they address factors that cause or contribute to the client's problems. Examples include assessing pain, turning a client, and teaching a client about relaxation. A physician-initiated intervention is one initiated by a physician in response to a medical diagnosis but is carried out by the nurse in response to a physician's order. Examples include writing a prescription for an opioid analgesic and ordering laboratory and diagnostic tests, such as a complete blood count and a chest x-ray.