Prep U Chapter 16: Outcome Identification and Planning

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. "Please tell me your thoughts about treating this diagnosis." c. "Do you want to be discharged without treatment?" d. "What are your plans after discharge?"

b. "Please tell me your thoughts about treating this diagnosis."

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? a. Nurses do not carry out physician-initiated interventions. b. Nurses do carry out interventions in response to a physician's order. c. Nurses are responsible for reminding physicians to implement orders. d. Nurses are not legally responsible for these interventions.

b. Nurses do carry out interventions in response to a physician's order.

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 reports no headache. b. Client is drowsy after lunch. c. Client is normotensive. d. Client lipids are within range.

c. Client is normotensive.

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? a. Surveillance b. Maintenance c. Supervisory d. Educational

d. Educational

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan? a. Initial b. Ongoing c. Discharge d. Standardized

d. Standardized

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

c. Psychomotor

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. a. Are the interventions compatible with other planned therapies? b. Are the interventions evidence-based? c. Are the interventions realistic and do they require resources available to the nurse? d. Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background? e. Are the interventions valued by the nursing staff?

a. Are the interventions compatible with other planned therapies? b. Are the interventions evidence-based? c. Are the interventions realistic and do they require resources available to the nurse? d. Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background?

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

a. Individualize the plan to the client.

Which guidelines should the nurse consider when writing outcomes? Select all that apply. a. The nurse should derive each set of outcomes from a combination of nursing diagnoses. b. At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. c. The nurse should not be concerned if the client and family do not value the outcomes as long as they support the plan of care. d. The nurse should write outcomes that are brief and specific and support the overall plan of care. e. The outcomes the nurse writes need not be supportive of the total treatment plan as long as they specify a goal. f. The nurse may write outcomes that do not specify a timeline as long as they are linked with other outcomes.

b. At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. d. The nurse should write outcomes that are brief and specific and support the overall plan of care.

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

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

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

a. discharge planning.

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 nurse has omitted the time frame. c. The nurse has omitted the defining characteristics. d. The outcome should indicate what the nurse will do.

b. The nurse has omitted the time frame.

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

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

Which is an example of a nurse-initiated intervention? a. Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. b. Administer oxygen at 4 L/min per nasal cannula. c. Administer a 1000-mL soap suds enema. d. Teach the client how to splint an abdominal incision when coughing and deep breathing.

d. Teach the client how to splint an abdominal incision when coughing and deep breathing.

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 a. does not contain documented scientific rationales. b. does not contain abbreviated nursing diagnoses. c. separates goal statements from the plan of care. d. separates outcome criteria from the plan of care.

a. does not contain documented scientific rationales.

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? a. Consult with another nurse. b. Seek research about the disorder. c. Follow institutional guidelines. d. Set priorities using client care standards.

b. Seek research about the disorder.

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? a. Process b. Structure c. Outcome d. Cost-effectiveness

c. Outcome

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? a. Add the nursing diagnosis: Risk for Self-Harm. b. Tell another nurse about this client statement. c. Encourage the client to join a therapy group. d. Document that the depression has resolved.

a. Add the nursing diagnosis: Risk for Self-Harm.

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. Encourage hourly use of the incentive spirometer. b. Promote oral fluid intake between meals. c. Provide oral pain medication before ambulation. d. Reassess in 4 hours and document the findings.

a. Encourage hourly use of the incentive spirometer.

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

a. Nurse-initiated interventions are derived from the nursing diagnosis.

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? a. On the client's admission to the hospital b. Once the client has received a discharge order c. As soon as possible after the client's surgery d. Once the client is admitted to the nursing unit from postanesthetic recovery

a. On the client's admission to the hospital

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. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. b. The nurse will help the client ambulate the length of the hallway once a day. c. Offer to help the client walk the length of the hallway each day. d. The client will become mobile within a 24-hour period.

a. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

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

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

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? a. Supportive b. Psychosocial c. Coordinating d. Supervisory

a. Supportive

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? a. The client will understand the effects of smoking related to heart disease. b. By 08/02, the client will state three therapeutic methods of reducing stress. c. By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. d. By 8/02, the client will state when to notify the health care provider after discharge

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

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? a. The client will perform range of motion exercises 3 times per day. Passive abduction with assistance b. 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. c. The client performed active range of motion exercises only twice d. today but states a goal of 3 times per day tomorrow.

b. 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.

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: a, identifies the unhealthy response preventing desired change. b. identifies factors causing undesirable response and preventing desired change. c. suggests client goals to promote desired change. d. identifies client strengths.

b. identifies factors causing undesirable response and preventing desired change.

The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate? a. "Nursing interventions are selected based on the etiology in the nursing diagnosis and must be compatible with other therapies planned for the client." b. "The client's developmental level, values, beliefs, and cultural and psychosocial background should be considered when selecting nursing interventions." c. "Nursing interventions should be consistent with standards of nursing care and research findings." d. "Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

d. "Nursing interventions are pretty much the same for clients that have the same medical diagnosis."