Chapter 16: Outcome Identification and Planning
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? "Nursing interventions are selected based on the etiology in the nursing diagnosis and must be compatible with other therapies planned for the client." "The client's developmental level, values, beliefs, and cultural and psychosocial background should be considered when selecting nursing interventions." "Nursing interventions should be consistent with standards of nursing care and research findings." "Nursing interventions are pretty much the same for clients that have the same medical diagnosis."
"Nursing interventions are pretty much the same for clients that have the same medical diagnosis." Rationale: Nursing interventions should be based on the etiology in the nursing diagnosis, be compatible with other planned therapies, be consistent with standards of care and research, and individualized for the client.
A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family? A plan designed to support the client physically A plan derived from a consensus of opinions of all staff members A plan with problems that are easily solved A plan made in conjunction with the hospital's ethics committee
A plan designed to support the client physically Rationale: An unconscious client who is unable to provide input into outcome identification depends on the nurse to make informed choices to support the client physically. This care plan would treat any life-threatening situations and act to prevent the development of unhealthy physical consequences. The nurse is in the best position to determine client needs and would not seek the opinion of all staff members or the ethics committee. The care plan would deal with all problems, not just those that are easily solved.
Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs? Cutting up food and opening drink containers for the client Seeking input from the client regarding preferences for a snack Providing the mother the phone number for the Poison Control Center Assisting the client to validate feelings regarding treatment options
Cutting up food and opening drink containers for the client Rationale: According to Maslow's Hierarchy of Needs, physiologic needs are essential to maintain life. These needs include oxygen, water, food, temperature, elimination, sexuality, physical activity, and rest. Cutting up food and opening drink containers for the client would meet the most basic need for food. The nurse is meeting safety needs by providing a mother with the phone number for the Poison Control Center. The nurse seeking input from the client regarding preferences for a snack is showing respect to the individual and meeting self-esteem needs. When assisting the client to validate feelings regarding treatment options, the nurse is acknowledging the uniqueness of the client and respecting the client's knowledge and feelings in solving problems to attain self-actualization.
A computerized information system developed to classify client outcomes is the: NANDA-International list Nursing Outcome Classification system International Classification of Diseases Clinical Care Classification System
Nursing Outcome Classification system Rationale: The Nursing Outcome Classification system organizes outcomes according to categories, classes, labels, indicators, and measurement activities. The remaining options do not classify client outcomes. NANDA-International is an organization that develops standardized terminology for nursing diagnosis to ensure client safety and improve client outcomes. The International Classification of Diseases is a classification system for classifying diseases according to diagnosis codes. The Clinical Care Classification System is a standardized system of codes used to label discrete components of nursing practice.
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. Present the client with videos and books about diet changes that reduce inflammation. Ask the client's learning style, then teach diet information using that style. Answer the client's questions about diet alterations, and then evaluate understanding
Start from client's knowledge, teach about diet modifications, and check for learning. Rationale: The nursing interventions written to assist a client to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what assessments need to be made and what nursing interventions, including teaching, counseling, and advocacy, need to be done. They should also include evaluation of the outcome of the intervention. "Start from client's knowledge, teach about diet modifications, and check for learning" provides the most comprehensive intervention for this client, as it includes assessment of the client's current level of knowledge, teaching, and evaluation of the teaching. None of the other answer options includes all three of these elements.
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 client will express an understanding of strategies for managing fatigue and shortness of breath. The client will ambulate 100 feet without supplementary oxygen or mobility aids. The client will demonstrate the correct use of a metered-dose inhaler.
The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. Rationale: Long-term outcomes require a longer period (usually more than a week) to be achieved than do short-term outcomes. They also may be used as discharge goals, in which case they are more broadly written and communicate to the entire nursing team the desired end results of nursing care for a particular client. Resumption of ADLs in the home setting is characteristic of a long-term outcome. Explaining energy-conservation techniques, mobilizing in the hospital, and demonstrating correct medication administration are short-term outcomes that may be accomplished prior to discharge.
When creating a care plan, which is the purpose of identifying the client outcome? To design a plan of care to address the health problem To evaluate the plan of care developed To provide a basis for the scientific rationale To coordinate the nursing intervention
To design a plan of care to address the health problem Rationale: The primary purpose of the outcome identification and planning step of the nursing process is to design a plan of care with and for the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes.
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? Posting the sign "NPO after midnight" over the bed Updating the diet orders in the client's plan of care Obtaining written consent for the diagnostic procedure Adding the diagnosis "Altered Nutrition, Less Than Required"
Updating the diet orders in the client's plan of care Rationale: The plan of care communicates three different types of nursing care: care related to meeting basic human needs, care related to nursing diagnoses, and care that must be coordinated with medical and interdisciplinary providers. Nutrition is a basic human need. The temporary need to withhold food and fluid should be documented in the record. The other options are not the best, most direct methods for conveying this information to all who may need it.
Which outcome statements are in the cognitive realm? Select all that apply. Within 1 week after teaching, the client will list three benefits of quitting smoking. By 6/8/20, the client will correctly demonstrate self-injecting insulin. After viewing the film, the client will verbalize four benefits of daily exercise. By 6/8/20, the client will describe a meal plan that is high in fiber. By 6/8/20, the client will correctly demonstrate ambulating with a walker.
Within 1 week after teaching, the client will list three benefits of quitting smoking. After viewing the film, the client will verbalize four benefits of daily exercise. By 6/8/20, the client will describe a meal plan that is high in fiber. Rationale: Cognitive outcomes describe increases in client knowledge or intellectual behaviors. Listing benefits of quitting smoking, describing meal plans, and verbalizing benefits of exercise demonstrate increased client knowledge. Administering an injection and correctly ambulating with a walker demonstrates a psychomotor outcome.
A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: a guideline. an algorithm. a critical pathway. an order set.
a guideline. Rationale: A guideline is defined as a broad, research-based practice recommendation that may or may not have been tested in clinical practice. An algorithm has intense specificity and provides no provider flexibility; it is used to manage high-risk groups within a cohort. A critical pathway represents a minimal practice standard for a specific client population. An order set includes preprinted provider orders used to expedite the order process.
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: discharge planning. initial planning. ongoing planning. comprehensive planning.
discharge planning. Rationale: Discharge planning begins at the time of admission with the nurse teaching the client and family specific skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse's admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship.
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: diagnosis. evaluation. intervention. goal.
intervention. Rationale: A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance client goals and outcomes. Nursing diagnoses are statements of the client's actual or potential health problems that the nurse is seeking to address through interventions and are the overarching driver of goal-setting, care planning, and interventions. Evaluation, the final phase of the nursing process, involves assessing the client's response to interventions on an ongoing basis and making any necessary adjustments and changes to the nursing care plan.
The nurse recognizes that identifying outcomes/goals must include: involvement of the client and family. input from the physician. input from the multidisciplinary team. involvement of the nurse manager and other staff nurses.
involvement of the client and family. Rationale: One of the most important considerations in writing outcomes is to encourage clients and families to be as involved in goal development as their abilities and interests permit. The more involved they are, the greater the probability that the goals will be achieved. Patient-centered care focuses on the client needs and desires and thus would not require input from the physician, the nurse manager, or multidisciplinary team.
According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is: physiological. behavioral. safety. family.
physiological. Rationale: The NIC is a comprehensive, evidence-based, standardized system for classifying nursing interventions. NIC groups interventions within seven domains, which, in order from the simplest to the most complex, are: Physiological: Basic; Physiological: Complex; Behavioral; Safety; Family; Health System; and Community.