NUR 290 ch. 14: Outcome Identification and Planning

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

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

A client is scheduled to be fitted with a prosthesis following the loss of the nondominant hand after a traumatic injury. Nurses have documented an outcome that states, "After attending multiple educational sessions, the client will demonstrate correct technique for applying the prosthesis." Which statement by the client would indicate a need to revise the plan of care related to this outcome?

"I'm not interested in wearing an artificial hand."

As part of an assignment, a nursing student is asked to create a concept map for a client. The student asks the instructor, "Why is this necessary? Isn't the plan of care enough?" Which response by the instructor would be most appropriate?

"The map helps you to think more critically about the relationship between concepts."

The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply.

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 manager is conducting peer reviews of the staff on the critical care unit. Which person would the nurse manager select to evaluate a registered nurse who is certified in critical care?

Another registered nurse with critical care certification

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.

Are the interventions compatible with other planned therapies? Are the interventions evidence-based? Are the interventions realistic and do they require resources available to the nurse? Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background?

An unlicensed assistive personnel (UAP) has worked on the postpartum unit for many years. The UAP has been oriented well and provides excellent client care. What duties could the professional nurse appropriately delegate to the UAP? Select all that apply.

Assisting the client with personal hygiene needs and ambulation Transporting the infant to the mother's room according to hospital policy

Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Bed bath for the newly admitted client who has multiple skin lesions

Which is a psychomotor client goal?

By 18AUG2015, the client will demonstrate improved motion in the left arm.

Which client outcome requires modification?

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

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem?

Client will alternate rest periods with exercise throughout the day.

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 increase nutrition, eating 75% of meals. Client will report pain is controlled at or below 3 of 10. Client will perform dressing change independently.

Which outcome is sufficiently measurable?

Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020.

The nurse manager on an orthopedic unit has determined that the nurses are not keeping the nursing diagnoses up-to-date on client care plans and, in turn, are not using the plan of care. What is a feasible approach to correcting this problem?

Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses.

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

Before implementing any planned intervention, which action should the nurse take first?

Reassess the client to determine whether the action is needed.

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?

Return the client to bed and provide pain relief measures.

Which action should the nurse perform during the planning step of the nursing process?

Selects nursing measures, including client education

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?

Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.

Which intervention does the nurse recognize as a collaborative intervention?

Teach the client how to walk with a three-point crutch gait.

In planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2016." Why is this outcome inadequate?

The chosen verb is not observable or measurable.

A client is on the surgical unit following resection of an intestinal tumor. The client is alert and oriented x3. Based on an assessment of the client, the physician writes a medical order to "ambulate with assistance" in the chart. This will be the client's first time ambulating. Which is the best nursing outcome for this client?

The client will ambulate with the assistance of a walker without falling within the next 4 hours.

Which is inappropriate to include in an outcome?

a flexible time-frame

Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?

altered gas exchange

A nursing student received a report on his assigned clients for the clinical day. Which client should the student nurse plan to assess first?

an asthma client who reports shortness of breath with a respiratory rate of 26 bpm

The nurse should evaluate client outcomes at which time?

as early as possible

What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system?

clinical pathways

For which client would a standardized plan of care most likely be appropriate?

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia

A client on the medical-surgical unit is scheduled for several diagnostic tests. The nurse is concerned that the tests will be too tiring for the client. What would be the nurse's most appropriate action?

Coordinate with the other disciplines to schedule the tests with adequate rest for the client.

For a client with a self-care deficit, the long-term goal is that the client will be able to dress oneself by the end of the 6-week therapy. For best results, when should the nurse evaluate the client's progress toward this goal?

as soon as possible

A client's care plan contains the following information. Which would the nurse identify as the client outcome criteria?

demonstrates coughing exercises at next session

The nurse is planning the care of a client who is receiving treatment for acute renal failure and who has begun dialysis 3 times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of an arteriovenous fistula." This outcome is classified as which?

psychomotor

Which action is appropriate when evaluating a client's responses to a plan of care?

Continue the plan of care if more time is needed to achieve the goals/outcomes.

These nursing diagnoses appear on a client's care plan. In what order will the nurse prioritize them?

Impaired Swallowing Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image

A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care?

Include the client and the client's power of attorney in the discussion.

Which outcome is correctly written?

On discharge, client will be able to list five symptoms of infection. Explanation:

Which is an example of a long-term goal for a client with asthma?

The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

The nurse reviews the plan of care for the client who experienced a left hip replacement to determine the day's care guidelines and outcomes. The type of plan of care the nurse is reviewing is a(n):

clinical pathway

A plan of care for a client with a low potassium level includes providing information about the effect of medications and about dietary intake of foods high in potassium. How would a nurse measure achievement of an outcome for this plan?

laboratory data

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client's care?

nurse case manager

A large university hospital has commissioned a multidisciplinary group to review client records following discharge to evaluate client outcomes and the character and quality of nursing care that clients receive. Which type of evauation process will take place?

nursing audit

The nurse should derive the outcomes for a client's care plan from:

the problem statement of the nursing diagnosis.

Which type of care plan is most likely to enable the nurse to take a holistic view of the client's situation?

concept map care plan

A nurse finds that a client who was admitted with pancreatitis and has been stable seems to be unusually quiet and withdrawn. Which intervention would be most appropriate at this time?

reassess the client for pain

A client had a cholecystectomy 2 hours previously and is waking up from anesthesia. The client asks, "how long it will be before I can go home?" The nurse responds that most clients are discharged within 2 days. The nurse's answer is most likely based on which piece of information?

the agency's critical path