PrepU - Chapter 16: Outcome Identification and Planning (Taylor: Fundamentals of Nursing, Ninth Edition)
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."
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.
Which provides the best framework for prioritizing client problems?
Maslow's hierarchy of needs
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? a. Septic workup due to blood pressure and heart rate elevation b. Narcotic analgesic to treat pain c. Isolation for suspected respiratory illness d. Acetaminophen to treat pain and fever
Narcotic analgesic to treat pain
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 patient 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?
Start from client's knowledge, teach about diet modifications, and check for learning
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?
Upon her admission to the hospital
For which client would a standardized plan of care most likely be appropriate?
a client who was admitted for shortness of breath and who has been diagnosed with pneumonia
A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?
Educational
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
Psychomotor
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
Discharge planning
Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?
Altered Gas Exchange
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 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.
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
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
Which statement correctly describes a nurse-initiated intervention?
Nurse-initiated interventions are derived from the nursing diagnosis.
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?
Nurses do carry out interventions in response to a physician's order.
Which elements are common to any type of plan of care? Select all that apply.
Nursing diagnoses Client goals Nursing interventions
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 planning
Which is an example of a nurse-initiated intervention?
Teach the client how to splint an abdominal incision when coughing and deep breathing.
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.
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.
The nurse recognizes that identifying outcomes/goals must include:
involvement of the client and family
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
Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer?
By discharge, client will perform hand hygiene before and after port care.
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.
A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client?
Ineffective Impulse Control
After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care?
It helps deliver holistic, goal-oriented, individualized care.
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 broad, research-based practice recommendation that may or may not have been tested in clinical practice is:
a guideline.
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 is caring for a client admitted for bowel obstruction, which now has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply. a. Allow the client to order favorite foods from the hospital menu. b. Begin feedings with clear broth. c. Consult with a dietitian regarding appropriate foods. d. Auscultate for bowel sounds.
b. Begin feedings with clear broth. c. Consult with dietitian regarding appropriate foods. d. Auscultate for bowel sounds.
Which is an appropriate expected outcome for a client? a) Client will perform complete ostomy care while bathing on the second postoperative day .b) After attending sibling classes, client will be happy about a new baby and demonstrate feeding .c) Client will ambulate safely with walker in the room within 3 days of physical therapy. d) By the next clinic visit, client will report taking antihypertensive medication.
c) Client will ambulate safely with walker in the room within
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
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 omitted the time frame.