Chapter 16: Outcome Identification & 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?

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

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction

(2) Ineffective Airway Clearance (4) Impaired Social Interaction (1) Disturbed Body Image (3) Spiritual Distress

Which is an appropriate expected outcome for a client?

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

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.

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 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?

Encourage hourly use of the incentive spirometer.

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 client will walk the length of the hallway assisted by the nurse.

Which accurately identify the characteristics of effective client goals represented in the acronym SMART? Select all that apply.

S = specific M = measurable A = attainable R = realistic T = timebound

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 is considering the needs of the postoperative client in the home setting. The nurse is performing:

discharge planning.

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

intervention.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in). By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

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.

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?

Narcotic analgesic to treat pain

A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? Actual Possible Risk Collaborative

Possible An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. A nurse sits down with a patient and prioritizes existing diagnoses. A nurse assesses a woman for postpartum depression during routine care. A nurse plans interventions for a patient who is diagnosed with epilepsy. A busy nurse takes time to speak to a patient who received bad news. A nurse reassesses a patient whose PRN pain medication is not working. A nurse coordinates the home care of a patient being discharged.

A nurse assesses a woman for postpartum depression during routine care. A busy nurse takes time to speak to a patient who received bad news. A nurse reassesses a patient whose PRN pain medication is not working.

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 nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself. Following physical therapy, patient will begin to gradually participate in walking/running events. By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events.

After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body.

A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? Offer the patient 60-mL fluid every 2 hours while awake. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20. At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day.

During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. Verbs to be avoided when writing outcomes include "know," "understand," "learn," and "become aware."

The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? Initial planning Standardized planning Ongoing planning Discharge planning

Ongoing planning Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

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 nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. The nurse formulates nursing diagnoses. The nurse identifies expected patient outcomes. The nurse selects evidence-based nursing interventions. The nurse explains the nursing care plan to the patient. The nurse assesses the patient's mental status. The nurse evaluates the patient's outcome achievement.

The nurse identifies expected patient outcomes. The nurse selects evidence-based nursing interventions. The nurse explains the nursing care plan to the patient.

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. The nurse uses a binary decision tree for stepwise assessment and intervention. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. The nurse uses a decision tree that provides intense specificity and no provider flexibility.

The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes.

A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concepts" that are being diagrammed in this plan? Protocols for treating the patient problem Standardized treatment guidelines The nurse's ideas about the patient problem and treatment Clinical pathways for the treatment of sickle cell anemia

The nurse's ideas about the patient problem and treatment A concept map care plan is a diagram of patient problems and interventions. The nurse's ideas about patient problems and treatments are the "concepts" that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient's situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.