Chapter 16 PrepU: Outcome Identification
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. Opioid 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
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. A plan designed to support the client physically B. A plan derived from a consensus of opinions of all staff members C. A plan with problems that are easily solved D. A plan made in conjunction with the hospital's ethics committee
A
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
The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome? A. Client will maintain nutritional intake without pain or diarrhea. B. Client will talk with campus cafeteria manager about identifying safe meals. C. Client will understand what inflammatory bowel disease is. D. Client will learn to cook foods that meet personal nutritional needs.
A
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
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
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
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: A. support system. B. medical orders. C. past medical history. D. condition.
D
The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) 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 the medications until the inflammation goes away." B. "I will take my medications on an empty stomach for maximum effect." C. "I should increase water intake if I have dark bowel movements." D. "I should call my health care provider if I have a sore that won't heal."
D
Which are characteristics of appropriate client outcome statements? Select all that apply. - Measurable - Realistic - Specific - Short-term - Broad in scope
measurable realistic specific
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
A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest, and the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as? A. Rationale B. Outcome C. Nursing intervention D. Nursing diagnosis
A
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
What are specific measurable and realistic statements of goal attainment? A. Nursing diagnoses B. Nursing interventions C. Evaluations D. Outcomes
D
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
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? A. Maintenance B. Surveillance C. Psychomotor D. Psychosocial
C
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
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
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? A. The nurse has not made any error in writing the outcome. B. The nurse has omitted the time frame. C. The nurse has omitted the defining characteristics. D. The outcome should indicate what the nurse will do.
B
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
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
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? A. Encourage hourly use of the incentive spirometer. B. Promote oral fluid intake between meals. C. Provide oral pain medication before ambulation. D. Reassess in 4 hours and document the findings.
A
The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply. - Demonstrate the correct use of crutches to the client prior to discharge. - The client will know how to dress the wound after receiving a demonstration. - After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn. - By 4/5/20, the client will demonstrate how to care for a colostomy. - The client will list the dangers of smoking and quit. - After counseling, the client will describe two coping measures to deal with stress.
After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn. By 4/5/20, the client will demonstrate how to care for a colostomy. After counseling, the client will describe two coping measures to deal with stress
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
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
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
Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal? A. Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. B. Assist the client to put on the clothing that goes over the operated leg. C. Tell the client's family to bring in clothes a size larger to make dressing easier. D. Arrange for the social worker to schedule home health care with discharge planning
A
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
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
Which outcome for a client with a new colostomy is written correctly? A. Explain to the client the proper care of the stoma by 3/29/20. B. The client will know how to care for the stoma by 3/29/20. C. The client will demonstrate proper care of the stoma by 3/29/20. D. The client will be able to care for stoma and cope with psychological loss by 3/29/20.
C
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
The nurse is developing goals for a newly admitted client with visual and auditory hallucinations. Which outcome is the priority for the client? A. Client will understand that the hallucinations aren't real in therapy sessions before discharge. B. Within 3 days, client will have an interaction with one other client in the day room without disruptive behavior. C. Client will verbalize side effects of antipsychotic medications within 24 hours. D. Within 2 days, client will perform personal hygiene without reminders.
B
A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the best documentation of the evaluation of this client? A. The client will perform range of motion exercises 3 times per day. B. Passive abduction with assistance C. The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day. D. The client performed active range of motion exercises only twice today but states a goal of 3 times per day tomorrow.
C
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
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
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
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? A. Start from client's knowledge, teach about diet modifications, and check for learning. B. Present the client with videos and books about diet changes that reduce inflammation. C. Ask the client's learning style, then teach diet information using that style. D. Answer the client's questions about diet alterations, and then evaluate understanding.
A
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
Which outcome is sufficiently measurable? A. Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020. B. Client will progress from clear fluid diet to full fluid diet without experiencing nausea. C. Increase client's diet from clear fluids to full fluids by 12/15/2020. D. Client will maintain adequate intake with no reports of nausea by 12/15/2020.
A
Which guidelines should the nurse consider when writing outcomes? Select all that apply. - The nurse should derive each set of outcomes from a combination of nursing diagnoses. At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. The nurse should not be concerned if the client and family do not value the outcomes as long as they support the plan of care. The nurse should write outcomes that are brief and specific and support the overall plan of care. The outcomes the nurse writes need not be supportive of the total treatment plan as long as they specify a goal. The nurse may write outcomes that do not specify a timeline as long as they are linked with other outcomes.
At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. The nurse should write outcomes that are brief and specific and support the overall plan of care.
The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply. - Client will receive influenza vaccine. - Client will increase nutrition, eating 75% of meals. - Client will report pain is controlled at or below 3 of 10. - Client will maintain oxygen saturation at 81%. - Client will perform dressing change independently.
Client will increase nutrition, eating 75% of meals. Client will report pain is controlled at or below 3 of 10. Client will perform dressing change independently.
A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? A. Surveillance B. Maintenance C. Supervisory D. Educational
D
A client has just given birth to a stillborn infant. The client is sobbing and says God is punishing the client for some bad choices in the past. The client reports having always believed in God as a loving and caring presence in life but now feeling that the client's faith is destroyed. Which nursing diagnoses would be appropriate for the nurse to include in this client's care plan? Select all that apply. - Spiritual Distress - Risk for Suicide - Defensive Coping - Impaired Parenting - Grieving
Spiritual Distress greiving
The nurse is caring for a client who is postoperative day one after undergoing a total knee replacement. The nurse is conducting a client assessment when taking which action(s)? Select all that apply. - checking the strength of pedal pulses - asking the client for a pain rating - reviewing the client's intraoperative record - observing the client's ability to move in the bed - determining effectiveness of pain medication
checking the strength of pedal pulses asking the client for a pain rating reviewing the client's intraoperative record observing the client's ability to move in the bed