Chapter 16 outcome identification and planning

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

A standardized care plan

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning

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

"I should call my health care provider if I have a sore that won't heal."

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

Algorithm

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client's spouse. What is the nurse's best course of action?

Ask the surgeon to wait until the client has had a chance to talk to the spouse.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

Which guideline should the nurse follow when including interventions in a plan of care?

Date the nursing interventions when written and when the plan of care is reviewed.

The nurse in a burn intensive care unit (BICU) is caring for a 3-year-old child who was burned with scalding hot water. The client has burns covering 75% of the body. The client's condition is critical but stable. At 1000, the nurse reassesses the client and finds that the client is agitated and pulling at the endotracheal tube. Which is the nurse's priority intervention for this client at this time?

Ensuring that the endotracheal tube is secure

A computerized information system developed to classify client outcomes is the:

Nursing Outcome Classification system

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?

Opioid analgesic to treat pain

A client is admitted to the mental health center after attempting suicide. Which client concern is the priority for the nurse to manage?

Risk of self-harm

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.

The nurse has assessed a client and determined that the client has abnormal breath sounds and low oxygen saturation level. The nurse is performing what type of nursing intervention?

Surveillance

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?

Surveillance

Which components must be included in an outcome? Select all that apply.

The action the client will perform The particular circumstances in which the outcome is to be achieved The client or some part of the client A target time by which the client is expected to be able to achieve the outcome

3m 59s Report this Question When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "The client will know how to self-administer prescribed bronchodilators using a nebulizer by 09/09/2020." Why is this outcome inadequate?

The outcome is not observable or measurable.

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?

developing the plan without client input

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 treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention

The nurse recognizes that identifying outcomes/goals must include: involvement of the client and family.

involvement of the client and family.

According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is:

physiological

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?

seek research about the disorder

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours?

client is normotensive

A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs?

on the client's admission to the hospital

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based on improvements in the client's condition. This is an example of which type of planning?

ongoing

Which are characteristics of appropriate client outcome statements? Select all that apply.

realistic, measurable, specific

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

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

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

Psychomotor

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?

outcome