Ch 16
ongoing
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?
Client will have formed stools within 24 hours.
A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?
Client is normotensive.
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?
condition
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:
"I will test my glucose level before meals and use sliding scale insulin."
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?
Start from client's knowledge, teach about diet modifications, and check for learning.
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?
discharge planning
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
Psychomotor
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
Educational
A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?
Demonstrate Choose
A nurse is developing short-term outcomes for a client with a nursing diagnosis of "Deficient Knowledge related to insulin self-administration as evidenced by statements of therapy being new and never having done it before." When writing the outcomes, which verbs would the nurse use to achieve a psychomotor change in behavior? Select all that apply.
Developing the plan without client input
A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?
intervention
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:
Teach the client how to splint an abdominal incision when coughing and deep breathing.
Which is an example of a nurse-initiated intervention?
On the client's admission to the hospital
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?
Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.
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?
By discharge from the fertility clinic, the client will achieve full-term pregnancy.
The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. When completing the plan of care, which outcome is written the clearest for working with the multidisciplary team?
The client will demonstrate proper care of the stoma by 3/29/20.
Which outcome for a client with a new colostomy is written correctly?
