Chapter 16: Outcome Identification and Planning PrepU

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. -Grieving -Defensive Coping -Risk for Suicide -Impaired Parenting -Spiritual Distress

-Spiritual Distress -Grieving 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 demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? -Supervisory -Maintenance -Surveillance -Educational

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.

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 -Process -Cost-effectiveness -Structure

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.

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

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

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

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

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

"Please tell me your thoughts about treating this diagnosis." In the planning stage of the nursing process, the nurse must focus on the client's interests and preferences, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.

A nurse administers an antihypertensive medication according to the standardized plan of care for a client admitted with uncontrolled hypertension. Which assessment information indicates the expected client outcome has been met within the first 24 hours? -Client reports no headache. -Client lipids are within range. -Client is drowsy after lunch. -Client is normotensive.

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

Nurse-initiated interventions 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.

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? -Psychosocial -Coordinating -Supportive -Supervisory

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.

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

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

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

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

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.

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? -Choosing actions that do not solve the problem -Developing the plan without client input -Failing to update the written plan of care -Beginning the plan without family to help

Developing the plan without client input 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. There is no indication that the nurse included strategies in the plan of care that did not solve the client's problem. There is no evidence that the care plan needed to be updated or that the nurse failed to do so. Although family support can be important to achieving client outcomes, not every client outcome requires family support.

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? -Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. -The client will become mobile within a 24-hour period. -The nurse will help the client ambulate the length of the hallway once a day. -Offer to help the client walk the length of the hallway each day.

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.

A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest, and the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as? -Nursing diagnosis -Rationale -Nursing intervention -Outcome

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

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

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.

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

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

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome? -The nurse has not made any error in writing the outcome. -The nurse has omitted the time frame. -The nurse has omitted the defining characteristics. -The outcome should indicate what the nurse will do.

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

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: -past medical history. -medical orders. -condition. -support system.

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

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.