Chapter 13: Outcome Identification and Planning
Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?
Altered Gas Exchange
A nurse administers clonidine according to the standardized plan of care for a client admitted with hypertension. Which assessment information deviates from the expected client outcome for the first 24 hours and requires nursing intervention?
Client gains 1 kg (2.2 lb) in 1 day
A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?
Client is normal tensive.
A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?
Client will have formed stools within 24 hours.
A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem?
Client will not leave the premises without a caregiver.
A nurse is planning nursing interventions for clients on a busy hospital unit. Which guideline would the nurse follow when designing the plan of care?
Date the nursing interventions when written and when the plan of care is reviewed.
A nurse is demonstrating foley catheter care to a client. Which type of nursing intervention does this best represent?
Educational
A nurse is caring for a client who was admitted 2 days ago following surgery. The client has diminished lung sounds in the posterior bases. What is the best action by the nurse?
Encourage hourly use of the incentive spirometer.
A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care?
Include the client and the client's power of attorney in the discussion.
A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?
Individualize the plan to the client.
The nurse is caring for a 48-year-old male client with a new colostomy. Which client goal for Mr. Conner is written correctly?
Mr. Conner will demonstrate proper care of stoma by 29MAR2015.
A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: T: 36.8°C sublingual, HR: 95, RR: 20, BP: 130/65. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. What order is the nurse likely to request first for the client?
Narcotic pain medication to treat pain
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?
Nurses do carry out interventions in response to a physician's order.
A computerized information system developed to classify client outcomes is the:
Nursing Outcome Classification
What are specific measurable and realistic statements of goal attainment?
Outcome criteria
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
Psychomotor
The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which example is a nurse-initiated intervention?
Teach client how to splint abdominal incision when coughing and deep breathing.
The nurse recognizes that an example of a cognitive outcome is:
The client identifies three foods high in potassium by August 8.
An older adult female client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease (COPD). Which statement constitutes a long-term outcome?
The client will return home able to conduct her activities of daily living (ADLs) without experiencing shortness of breath.
The nurse has identified the following outcome for the client: The client will have a soft formed stool. Which error has the nurse made in writing the outcome?
The nurse has omitted the time frame.
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
condition
When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:
identifies factors causing undesirable response and preventing desired change.
A client is required to be n.p.o. for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client?
updating the diet orders in the client's plan of care
A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?
A standardized care plan
A nurse is caring for a client with a bowel obstruction that 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.
Auscultate for bowel sounds. Begin feedings with clear broth. Consult with dietitian regarding appropriate foods.
Which statement correctly describes a nurse-initiated intervention?
Nurse-initiated interventions are derived from the nursing diagnosis.
A nurse is caring for a 48-year-old man 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?
Outcome evaluation
The nurse admitting a client with a new diagnosis of diverticulitis plans to teach the client about managing the disorder after discharge. What nursing intervention most completely meets the client's needs?
Start from client's knowledge, teach about diet modifications, and check for learning