Prep-U Chap 18

A mother brings an infant into the clinic for a well-baby visit. The mother reports being concerned at discharge from the hospital after giving birth about being able to get the infant to latch on for breastfeeding. Now, however, the mother reports success with breastfeeding. and the nurse finds that the baby is gaining weight appropriately. Which is an appropriate evaluative statement for this client?

"8FEB2016. Goal met. Mother reports that breastfeeding is going well with the infant eating every 2-3 hours and attaching to the nipple easily. Infant is gaining weight."

The nurse determines that a client has not met the goal of consuming at least 80% of each meal served by a designated date. Which would be appropriate responses by the nurse to the client regarding this lack of goal attainment? Select all that apply

-"What kinds of things have we been doing to increase your appetite?" -"Do you think you could meet the goal if we check on it in one week or so?" -"Do you think it is possible that you will be able to eat 80% of the food served here?"

A client reports to the nurse quitting smoking 6 months ago after being diagnosed with lung cancer. The nurse recognizes this change in behavior is which type of outcome?

Affective

A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client?

Asking whether the client feels less anxious 30 minutes after administering the medicine

The nurse on a busy acute care floor identifies that several clients with heart failure are being readmitted within 2 weeks of discharge. Which step in performance improvement is the nurse demonstrating?

Discovering a problem

Which action should the nurse take during the evaluation phase of the nursing process?

Document reassessment of pain after medication administration.

The nurse is caring for a postoperative client who reports ineffective pain management with pain rated a 7 on a 0-10 rating scale. Based on the information provided by the client, which step should the nurse take first to modify the care plan?

Evaluate the use of current pain relief measures.

All of the activities listed are related to evaluation, but which activity is the priority concern for nurses?

Meeting the care needs of clients

The nursing staff on a hospital unit uses peer review to improve professional performance. Who performs the review?

Nurses

The 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, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome

A mother brings an infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states, "The infant will double birth weight by 6 months of age." This is an example of which type of outcome statement?

Physical Changes

Prior to the first visit following gastrectomy, the client will have a weight loss of 10 lb (4.5 kg). This is an example of which type of evaluative statement?

Physical Changes

A nurse assures a client newly admitted to the clinical unit that the client will not be harmed by any errors and can expect to be safe in the facility. This assurance represents which expectation of the health care environment?

Safety

A client who was admitted to the acute care unit with angina pectoris is no longer having chest pain. Based on this assessment, what does the nurse decide to do with the plan of care for chest pain?

Terminate the plan of care related to the nursing diagnosis of chest pain.

Which nursing action reflects evaluation?

The nurse assesses the client's response to pain medication.

A nurse is evaluating nursing care and client outcomes by using a retrospective evaluation. Which action would the nurse perform in this approach?

The nurse devises a postdischarge questionnaire to evaluate client satisfaction.

A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse?

The nurse evaluates the client's goal/outcome achievement.

Why are quality-assurance programs important in nursing?

They enable nursing to be accountable for the quality of care.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:

a cognitive outcome

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?

"Demonstrated Steps"

The nurse and client have written the following outcome measure: "The client will eat at least 80% of each meal offered by 3/2." When should the nurse collect information to evaluate this outcome?

At the completion of each meal.

A nurse caring for an older adult client who has dementia observes another nurse putting restraints on the client without a physician's order. The client is agitated and not cooperating. What would be the best initial action of the first nurse in this situation?

Confront the nurse and explain how this could be dangerous for the client

"The levels of performance accepted by and expected of nursing staff or other health team members" defines

Standards

While auscultating a client's lung sounds, the nurse notes crackles in the left lower lobe, which were not present at the start of the shift. The nurse is engaged in which type of nursing intervention?

Surveillance

A new mother is having difficulty breastfeeding a newborn infant. A goal was established stating that the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports having discontinued breastfeeding. The nurse evaluates the original goal as:

Completely unmet