Fundamentals PrepU - Chapter 8: Outcome Identification and Planning

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 take my medications between meals for maximum effect." "I will mix insulin glargine with insulin lispro at bedtime." "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." Explanation: 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.

Which actions occur during the initial planning of client care? Select all that apply. A) After the initial plan is developed, the nurse prioritizes nursing diagnoses. B) The nurse who performs the admission nursing history and physical assessment makes the initial plan. C) The nurse collects new data and analyzes them to make the plan more specific and effective. D) The nurse making the initial plan focuses on using education and counseling skills to help the client carry out necessary self-care behaviors at home. E) The nurse uses tailored plans as opposed to standardized care plans as a basis for the initial plan. F) The nurse identifies client goals and the related nursing care in the initial plan.

A) After the initial plan is developed, the nurse prioritizes nursing diagnoses. B) The nurse who performs the admission nursing history and physical assessment makes the initial plan. F) The nurse identifies client goals and the related nursing care in the initial plan. Explanation: The nurse who performs the admission process for the client is best prepared to initiate a plan of care because this nurse knows the nursing history and physical assessment better than other staff members at this time. The nurse identifies the initial client goals at this time so that the nurse can establish a plan of care. Nursing diagnoses must be determined before the remainder of the plan of care can be developed. Standardized, not tailored, plans of care are useful for initial care planning as long as they are individualized to the client. Collecting additional new data would occur during ongoing, not initial, planning. While discharge planning should be started upon admission, the initial care plan does not have to focus on self-care behaviors for the home if this is not a priority at the time of admission, or if self-care is not possible.

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? A) Client is normotensive. B) Client reports no headache. C) Client lipids are within range. D) Client is drowsy after lunch.

A) Client is normotensive.

A nurse assesses the vital signs of a client who is one day postoperative following a colostomy. The nurse then uses the data to update the client plan of care. What are these actions considered? A) Ongoing planning B) Discharge planning C) Initial planning D) Comprehensive planning

A) Ongoing planning Explanation: Ongoing planning is carried out by any nurse who interacts with the client. Its chief purpose is to keep the plan up-to-date to facilitate the resolution of health problems, manage risk factors, and promote function. The nurse caring for the client uses new data as they are collected and analyzed to make the plan more specific and accurate and, therefore, more effective. Comprehensive planning involves establishing a plan of care that addresses all aspects of the client's care needs and updating that plan of care as needed until the client is discharged. Comprehensive planning has three phases: Initial planning, ongoing planning, and discharge planning. Initial planning is performed by the nurse with the admission nursing history and the physical assessment and results in the development of a comprehensive plan of care that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate client goals and the related nursing care. In acute care settings, discharge planning begins when the client is admitted for treatment—or even before admission. It ensures that the nurse uses teaching and counseling skills effectively to help the client and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors at home competently.

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to lunch and successfully drew up and administered the insulin while the nurse observed. How should the nurse follow up this observation? A) Record an evaluative statement in the client's plan of care. B) Ask the nurse who wrote the plan of care to document this development. C) Remove the outcome from the client's care plan. D) Reassess the client's psychomotor skills at dinner time.

A) Record an evaluative statement in the client's plan of care.

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? A) Verb (action) B) Subject C) Performance criteria D) Conditions

A) Verb (action)

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using: A) assessment skills. B) client's records. C) supervisor's advice. D) nursing books.

A) assessment skills.

The nurse is caring for a client with urinary retention. The nurse is carrying out the implementation step in the nursing process when taking which action(s)? Select all that apply. A) inserting a foley catheter B) providing client education C) reviewing the client's health history D) administering medication as prescribed E) checking bladder volume with a scanner

A) inserting a foley catheter B) providing client education D) administering medication as prescribed Explanation: Implementation is the fourth step in the nursing process. Implementation means carrying out the plan of care. These are any interventions or actions the nurse takes in response to assessment findings that have led to the plan of care. The nurse implements medical orders as well as nursing orders, which should complement each other. Inserting a foley catheter, administering medication and providing client education are all examples of nursing interventions. Assessment is the first step in the nursing process. It is the systematic collection of facts or data. During the assessment step in the nursing process, the nurse collects information to determine areas of abnormal function, risk factors that contribute to health problems, and client strengths. Scanning the bladder for urine volume and reviewing the client's health history are examples of data collection the nurse undertakes while completing a client assessment.

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? A) Client will increase protein intake in small frequent meals. B) Client will alternate rest periods with exercise throughout the day. C) Client will use oxygen by nasal cannula when short of breath. D) Client will consistently perform pulmonary exercises.

B) Client will alternate rest periods with exercise throughout the day.

What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system? A) Computerized plans of care B) Clinical pathways C) Student care plans D) Kardex care plans

B) Clinical pathways

Which group of terms best describes a nurse-initiated intervention? A) Other health care providers, skill acquisition B) Medical diagnosis, medication administration C) Autonomous, clinical judgment, client outcomes D) Dependent, health care provider-ordered, recovery

C) Autonomous, clinical judgment, client outcomes Explanation: A nursing intervention is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes. Nurse-initiated interventions are autonomous (independently performed). Medical diagnoses are constructed by health care providers, not nurses. Medication administration is an example of a health care provider-initiated nursing intervention, as it requires an order from a health care provider. Other health care providers neither initiate nor carry out nursing-initiated interventions. Nursing-initiated interventions pertain to actions nurses can initiate

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? A) Client will eat small meals of bland foods for 3 days. B) Client will maintain adequate hydration within 2 days. C) Client will have formed stools within 24 hours. D) Client will identify the food that caused the condition within 3 hours.

C) Client will have formed stools within 24 hours.

Which is a common error nurses make when writing client outcomes? A) Making the outcome measurable and including actions that are observable B) Including a target time by which the client is expected to achieve the outcome C) Expressing the client outcome as a nursing intervention D) Including a subject, verb, conditions, performance criteria, and target time

C) Expressing the client outcome as a nursing intervention

A nurse has identified on the plan of care for a client a nursing diagnosis of "Anxiety related to concerns about cancer treatment as evidenced by client's statement." One of the interventions that the nurse writes on the plan of care is to encourage the client to verbalize his feelings about the diagnosis and its effect on his quality of life. The nurse has identified which type of nursing intervention? A) Educational B) Psychomotor C) Psychosocial D) Sociocultural

C) Psychosocial

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

C) Start from client's knowledge, teach about diet modifications, and check for learning.

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? A) The nurse has not made any error in writing the outcome. B) The outcome should indicate what the nurse will do. C) The nurse has omitted the time frame. D) The nurse has omitted the defining characteristics.

C) The nurse has omitted the time frame. Explanation: 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.

The nurse recognizes that identifying outcomes/goals must include: A) involvement of the nurse manager and other staff nurses. B) input from the multidisciplinary team. C) involvement of the client and family. D) input from the health care provider.

C) involvement of the client and family.

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? A) "Client tries using relaxation as a means to cope." B) "Client will learn to cope more effectively." C) "Client will list positive coping strategies and use them." D) "Client will identify one coping strategy to try by end of week."

D) "Client will identify one coping strategy to try by end of week." Explanation: An appropriate outcome includes the client, an action verb, the circumstances by which the outcome is to be achieved, the performance criteria, and time frame. Identifying one coping strategy to try by the end of the week meets these criteria. The statement about the client learning to cope more effectively is not measurable. The statement about listing positive coping strategies and using them includes more than one behavior to evaluate, making it difficult to evaluate achievement. The statement about using relaxation is vague and not really measurable.

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

D) "Please tell me your thoughts about treating this diagnosis." Explanation: 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 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? A) Beginning the plan without family to help B) Failing to update the written plan of care C) Choosing actions that do not solve the problem D) Developing the plan without client input

D) Developing the plan without client input

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? A) Reassess in 4 hours and document the findings. B) Provide oral pain medication before ambulation. C) Promote oral fluid intake between meals. D) Encourage hourly use of the incentive spirometer.

D) Encourage hourly use of the incentive spirometer. Explanation: Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve th

A nurse working in a critical care unit has formulated the following nursing diagnoses for a client. Which nursing diagnosis likely would be the priority? A) Fatigue related to immobility B) Stress Urinary Incontinence C) Impaired Skin Integrity related to surgery D) Impaired Gas Exchange

D) Impaired Gas Exchange Explanation: Impaired Gas Exchange is a high-priority nursing diagnosis because it may be life threatening if proper interventions are not initiated. Fatigue, Stress Urinary Incontinence, and Impaired Skin Integrity are medium-priority nursing diagnoses because they could result in unhealthy consequences but are not life threatening.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? A) Identify the appropriate nursing diagnoses. B) Expect to modify the plan significantly. C) Include the rationale for the interventions. D) Individualize the plan to the client.

D) Individualize the plan to the client.

What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)? A) Nurses do not carry out health care provider-initiated interventions. B) Nurses are responsible for reminding health care providers to implement orders. C) Nurses are not legally responsible for these interventions. D) Nurses do carry out interventions in response to a health care provider's order.

D) Nurses do carry out interventions in response to a health care provider's order.

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? A) The nurse will help the client ambulate the length of the hallway once a day. B) Offer to help the client walk the length of the hallway each day. C) The client will become mobile within a 24-hour period. D) Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

D) Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. Explanation: 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.

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to lunch and successfully drew up and administered the insulin while the nurse observed. How should the nurse follow up this observation? A) Reassess the client's psychomotor skills at dinner time. B) Ask the nurse who wrote the plan of care to document this development. C) Remove the outcome from the client's care plan. D) Record an evaluative statement in the client's plan of care.

D) Record an evaluative statement in the client's plan of care.

In planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2016." Why is this outcome inadequate? A) The statement expresses a client outcome as a nursing intervention. B) The outcome is not related to an independent nursing action. C) The outcome does not specify the conditions in which it will be achieved. D) The chosen verb is not observable or measurable.

D) The chosen verb is not observable or measurable. Explanation: The verb in this outcome "know" is not directly measurable or observable. The verb "demonstrate" would be more appropriate. Educating a client on how to use his nebulizer is an independent nursing action. The outcome is not expressed as a nursing intervention and conditions are not likely necessary for this outcome.

Which is an example of a long-term outcome for a client with asthma? A) By day 3 of hospitalization, the client will verbalize knowledge of factors that exacerbate the symptoms of asthma. B) Within 1 hour after a nebulizer treatment, adventitious breath sounds and cough will decrease. C) Within 72 hours after admission, the client's respiratory rate will return to normal and retractions disappear. D) The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

D) The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack. Explanation: Long-term outcomes require a longer period (usually more than a week) to be achieved than do short-term outcomes. They also may be used as discharge goals, in which case they are more broadly written and communicate to the entire nursing team the desired end results of nursing care for a particular client. An example of a long-term outcome is "The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack." The other three examples are short-term outcomes that focus on short-term goals related to the period of time during hospitalization.

What is the primary purpose of the outcome identification and planning step of the nursing process?

To design a plan of care for and with the client Explanation: The primary purpose of outcome identification and planning is to design a plan of care for (and with) the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes. The assessment phase is when the nurse collects and analyzes data to establish a database. The diagnosis phase is when the nurse analyzes the data and writes appropriate client-centered nursing diagnoses.