Chapter 16: Outcome Identification and Planning

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using? A. A standardized care plan B. An order set C. Guidelines D. An algorithm

A. A standardized care plan

What verbs should the nurse use to write outcomes that are measurable? Select all that apply. A. Know B. Define C. Hear D. Verbalize E. Feel

B. Define D. Verbalize

The nurse has established client outcomes and outcome criteria. What should the nurse do next? A. Establish priorities B. Write a client plan of care C. Determine client goals D. Identify objectives

B. Write a client plan of care

Which phase of the nursing process most involves establishing priorities? A. Assessment B. Diagnosis C. Outcome identification and planning D. Implementation

C. Outcome identification and planning

When establishing client outcomes with the client, what is the qualifier in the outcome? A. The short-term goal B. The long-term goal C. The problem statement D. The outcome parameter

D. The outcome parameter

These nursing diagnoses appear on a client's care plan. Place in the order in which the nurse will prioritize acting upon them. Use all options. Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image Impaired Swallowing

1. Impaired Swallowing 2. Fluid Volume Deficit 3. Risk for Impaired Skin Integrity 4. Altered Body Image

According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is: A. physiological. B. behavioral. C. safety. D. family

A. Physiological

A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client? The client will ambulate with assistance by the nurse to a bedside chair. A. The client will ambulate with assistance by the nurse to a bedside chair. B. The client will return to performing activities of daily living. C. The client will walk 1 mile briskly five times per week. D. The client will not undergo repeat surgery.

A. The client will ambulate with assistance by the nurse to a bedside chair.

*What are specific measurable and realistic statements of goal attainment? A. Nursing diagnoses B. Nursing interventions C. Evaluations D. Outcomes

D. Outcomes

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

A. involvement of the client and family.

A computerized information system developed to classify client outcomes is the: A. NANDA-International list B. Nursing Outcome Classification system C. International Classification of Diseases D. Clinical Care Classification System

B. Nursing Outcome Classification system

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? A. Interrupted Breastfeeding B. Ineffective Thermoregulation C. Altered Gas Exchange D. Impaired Parenting

C. Altered Gas Exchange

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 elements are common to any type of plan of care? Select all that apply. A. Nursing diagnoses B. Client goals C. Nursing interventions D. Past medical history E. Medical diagnose

A. Nursing diagnoses B. Client goals C. Nursing interventions

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. Conditions D. Performance criteria

A. Verb (action)

*Which action should the nurse perform during the planning phase of the nursing process? A. Assess the client's overall health. B. Identify measurable goals or outcomes. C. Analyze the client's response to medicines. D. Identify the client's health-related problems.

B. Identify measurable goals or outcomes.

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority? A. Evaluate the need for antibiotics. B. Resolve the client's anxiety. C. Provide preoperative education. D. Prepare the client for surgery

B. Resolve the client's anxiety.

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.

Which is the primary benefit of outcome identification? A. It allows the nurse to evaluate the outcomes. B. It promotes the client being an active participant in care. C. It promotes an effective diagnostic process. D. It allows for the identification of proper diagnoses.

B. It promotes the client being an active participant in care.

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

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

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

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

The nurse is caring for Isabel, a 45-year-old ventilator-dependent quadriplegic. The nurse is in the process of placing IV access when the ventilator alarms occlusion. The nurse assesses Isabel, and she appears mildly uncomfortable but is not in acute distress. What is the nurse's priority in the nursing outcome planning? A. Continue to place the IV. B. Ask Isabel to cough and clear her tracheostomy tube. C. Assess tracheostomy for patency. D. Call respiratory therapy for help.

C. Assess tracheostomy for patency.

*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.

Which is an appropriate expected outcome for a client? A. By the next clinic visit, client will report taking antihypertensive medication. 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. Client will perform complete ostomy care while bathing on the second postoperative day.

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

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: A. diagnosis B. evaluation. C. intervention D. goal

C. Intervention

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. Initial planning B. Comprehensive planning C. Ongoing planning D. Discharge planning

C. Ongoing planning

Which phase of the nursing process most involves establishing priorities? A. Assessment B. Diagnosis C. Outcome identification and planning D. Implementation

C. Outcome identification and planning

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

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

A. involvement of the client and family.

Which are characteristics of appropriate client outcome statements? Select all that apply. A. Measurable B. Realistic C. Specific D. Short-term E. Broad in scope

A. Measurable B. Realistic C. Specific

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 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? A. Posting the sign "NPO after midnight" over the bed B. Updating the diet orders in the client's plan of care C. Obtaining written consent for the diagnostic procedure D. Adding the diagnosis "Altered Nutrition, Less Than Required"

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

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? A. "I will take insulin until my blood sugar levels are normal." B. "I will take my medications between meals for maximum effect." C. "I will mix insulin glargine with insulin lispro at bedtime." D. "I will test my glucose level before meals and use sliding scale insulin."

D. "I will test my glucose level before meals and use sliding scale insulin."

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. Choosing actions that do not solve the problem B. Failing to update the written plan of care C. Beginning the plan without family to help D. Developing the plan without client input

D. Developing the plan without client input

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

A. Client will have formed stools within 24 hours.

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem? A. Client will not leave the premises without a caregiver. B. Client will wear an ID bracelet with name and contact information. C. Client will identify landmarks that indicate location of home. D. Client will consistently return to the police station when lost.

A. Client will not leave the premises without a caregiver.

Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs? A. Cutting up food and opening drink containers for the client B. Seeking input from the client regarding preferences for a snack C. Providing the mother the phone number for the Poison Control Center D. Assisting the client to validate feelings regarding treatment options

A. Cutting up food and opening drink containers for the client

A nurse is developing short-term outcomes for a client with a nursing diagnosis of "Deficient Knowledge related to insulin self-administration as evidenced by statements of therapy being new and never having done it before." When writing the outcomes, which verbs would the nurse use to achieve a psychomotor change in behavior? Select all that apply. A. Demonstrate B. Choose C. Understand D. Explain E. Define

A. Demonstrate B. Choose

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. Narcotic analgesic to treat pain B. Septic workup due to blood pressure and heart rate elevation C. Isolation for suspected respiratory illness D. Acetaminophen to treat pain and fever

A. Narcotic analgesic to treat pain

Which is most important for the nurse to include in a client's plan of care? A. Nursing interventions B. Evaluation C. Assessment data D. Medical diagnoses

A. Nursing interventions

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.

What behaviors reflect planning? Select all that apply. A. The nurse decides to assist the client with ambulation in the hallway twice per shift. B. The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. C. The nurse considers the developmental level of the client when selecting education materials. D. The nurse assesses the client's usual sleep routine. E. The nurse assists the client with bathing, grooming, and dressing.

A. The nurse decides to assist the client with ambulation in the hallway twice per shift. B. The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. C. The nurse considers the developmental level of the client when selecting education materials.

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. a clinical pathway. B. an order set. C. an algorithm. D. a protocol.

A. a clinical pathway.

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.

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.

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."

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. Auscultate for bowel sounds. C. Begin feedings with clear broth. D. Consult with a dietitian regarding appropriate foods.

B. Auscultate for bowel sounds. C. Begin feedings with clear broth. D. Consult with a dietitian regarding appropriate foods.

Which client outcome requires modification A. Client will correctly self-administer subcutaneous insulin before discharge. B. By the end of instruction, client will know how to perform dressing changes. C. Client will demonstrate safe transfers from bed to chair within 24 hours. D. Within 2 days, client will describe two responses to firing of the internal defibrillator.

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

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.

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 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? A. Adjust expected outcome to have client ambulate a shorter distance. B. Return the client to bed and provide pain relief measures. C. Ask the client to describe a personal walking goal. D. Review evidence-based interventions for the client's pain

B. 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? 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.

*The nurse recognizes that an example of a cognitive outcome is: A. The client demonstrates self-catheterization using clean technique by June 3. B. The client identifies three foods high in potassium by August 8. C. The client accurately measures the radial pulse for 1 minute by February 2. D. The client verbalizes increased confidence in testing glucose levels.

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

A client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a non blanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take? A. The nurse repositions the client to the client's back and documents the intervention in the client's record. B. The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour. C. The nurse repositions the client to the left side and plans to return in 2 hours to reassess the reddened area on the client's right trochanter. D. The nurse repositions the client to the client's back and documents the condition of the client's skin in the medical record.

B. The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour.

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.

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