chapter 17 prep u

Which outcome is sufficiently measurable?

Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020.

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

-Measurable -Realistic -Specific

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?

Add the nursing diagnosis: Risk for Self-Harm

The nurse is selecting interventions after gathering and analyzing client data. Interventions that the nurse includes will meet what criterion?

Aligned with a goal

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?

Altered Gas Exchange

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority?

By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms

Which client outcome requires modification?

By the end of instruction, client will know how to perform dressing changes.

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs?

Cutting up food and opening drink containers for the client

What verbs should the nurse use to write outcomes that are measurable? Select all that apply.

Define Verbalize

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.

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

Nursing Outcome Classification system

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.

When a nurse documents an intervention involving a one-person assist of a client to the chair, which type of nursing intervention does this represent?

Psychomotor

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 recognizes that an example of a cognitive outcome is:

The client identifies three foods high in potassium by August 8.

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 health care provider 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?

The client will ambulate with the assistance of a walker without falling within the next 4 hours

Which outcome for a client with a new colostomy is written correctly?

The client will demonstrate proper care of the stoma by 3/29/20.

Which actions occur during the initial planning of client care? Select all that apply.

The nurse who performs the admission nursing history and physical assessment makes the initial plan. After the initial plan is developed, the nurse prioritizes nursing diagnoses. The nurse identifies client goals and the related nursing care in the initial plan.

Which is an example of a psychomotor outcome?

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

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

discharge planning.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

Which elements are common to any type of plan of care? Select all that apply.

Nursing diagnoses Client goals Nursing interventions

A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client?

The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day.

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?

Updating the diet orders in the client's plan of care

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is:

a guideline.

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

physiological.

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

"Client will identify one coping strategy to try by end of week."

A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family?

A plan designed to support the client physically

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.

Nurses on an orthopedic nursing unit use standardized care plans that incorporate nursing, physical therapy, occupational therapy, and case management actions for clients who experience a particular surgery. Which type of care plan do these nurses use?

Clinical pathway

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?

Comfort the client and family

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 has what characteristic?

Does not contain explicit scientific rationales.

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 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 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

Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal?

Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.

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?

Verb (action)

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 clinical pathway.

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.

Which is an appropriate expected outcome for a client?

Client will ambulate safely with walker in the room within 3 days of physical therapy.

Which statement on a plan of care should a nurse identify as a nursing intervention?

Perform range-of-motion exercises to all of the client's joints each morning.

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?

The client will understand the effects of smoking related to heart disease.

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."

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 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?

Client will alternate rest periods with exercise throughout the day.

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

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?

Return the client to bed and provide pain relief measures.

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.

When planning a client's care, the nurse has drafted specific, measurable and realistic statements of goal attainment. What component of the care planning process has the nurse included?

Outcomes

The nurse is developing goals for a client who has been admitted for an acute myocardial infarction. Which goal written by the nurse requires revision?

The client will understand the effects of smoking related to heart disease

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.

Are the interventions compatible with other planned therapies? 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?

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?

Outcome

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?

Deficient Diversional Activity

The nurse developed a plan for a client and has been working with the client for several months. The client reports feeling better due to an ability now to participate actively in water aerobics. What type of outcome is this?

Psychomotor

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?

The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath.