ch. 13 Outcome identification and planning

What describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

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 clients needs?

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

The nurse recognizes that identifying outcomes/goals must include

involvement of the client and family.

The nurse is developing outcomes for the care plan of a client admitted with Parkinson's disease. The nurse will derive the outcomes for this client's care plan from:

the problem statement of the nursing diagnosis.

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 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.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing

INTERVENTION.

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.

A nursing student is writing a student care plan for an assigned client. When identifying specific interventions to be sed, which aspect would the student need to include with the interventions?

Scientific rationales. A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes. Nursing interventions are actions preformed by the nurse to - Monitor patient health status and response to treatment -reduce risks -resolve, prevent, or manage problems -promote independence with ADL -PROMOTE OPTIMUM SENSE OF PHYSICAL, PSYCHOLOGICAL, AND SPRITIAL WELL-BEING. -give patients the information they need to make informed decisions and be independent.

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 her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?

Upon her admission to the hospital

Nursing interventions:

a nursing intervention describes, and thus communicates to the entire nursing staff and health care team, the specific nursing care to be implemented for the patient. Should include Date Verb: action to be performed. subject: Who is to do it Descriptive phrase: how, when, where, how often, how long, or how much. assist the patient meet specific outcomes related directly to one outcome. Example of a good nursing intervention: Offer patient 60 mL water or juice (prefers orange juice or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake.