ch 14 Outcome Identification and Planning

Which of the following nursing diagnosis is high priority?

Ineffective breathing patterns

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

Intervention

The nurse recognizes that encouraging the parents to sleep in the room with a toddler admitted with acute glomerulonephritis meets which of Maslow's human needs?

Love and belonging needs

A patient was admitted 2 days ago with sepsis. The nurse updates the patient's care plan based upon improvements in his condition. This is an example of which type of planning?

Ongoing planning

What are specific measurable and realistic statements of goal attainment?

Outcome criteria

The most basic level of nursing interventions is

Physiologic

While developing the plan of care for a new patient on the unit the nurse must identify expected outcomes that are appropriate for the new patient. What is a resource for identifying these appropriate outcomes?

The Nursing-Sensitive Outcomes Classification (NOC)

Which of the following is a correctly written client goal?

The client will ambulate 10 feet with a walker by October 12.

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?

The nurse has omitted the time frame.

An elderly female patient has been admitted to hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which of the following statements constitutes a long-term outcome?

The patient will return home able to conduct her activities of daily living without experiencing shortness of breath.

The nurse is developing outcomes for the care plan of a patient admitted with Parkinson's disease. The nurse will derive the outcomes for this patient's care plan from:

the problem statement of the nursing diagnosis.

Which of the following are verbs that are helpful in writing measurable outcomes? Select all that apply.

• Define • Verbalize

Which of the following reflect outcome identification? Select all that apply.

• The client indicates the desire to achieve self-administration of insulin. • The client identifies "3 or less" as the desired level of anxiety.

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 pretty much the same for clients that have the same medical diagnosis."

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the healthcare facility. The nurse determines the client's priorities for care using which of the following?

Assessment skills

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

Condition

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

Discharge planning

Which of the following actions are included in the planning process when a nurse is caring for an elderly client with AIDS?

Identify measurable goals or outcomes

The nurse recognizes that identifying outcomes/goals must include which of the following?

Involvement of the patient and family

After the health history and admission assessment are completed the nurse establishes a care plan for the patient. What is the rationale for documenting and planning the patients' care?

It helps deliver holistic, goal-oriented, individualized care.

Data relevant to a new patient's nursing care are recorded in a folder. On the outside of the folder is the patient's profile and orders related to diet and activity levels, while on the inside is the patient's individualized nursing care plan. The hospital unit where this patient is receiving care utilizes which of the following plans of care?

Kardex

The nurse, in collaboration with the patient's family, is assigning priorities related to the care of the patient. The nurse explains that when setting priorities it is important to look at the urgency of specific problems. What provides the best framework for prioritizing patient problems?

Maslow's hierarchy of needs

A nurse is formulating a nursing plan of care for a client based on assessment data. When writing this plan, which of the following would be most important for the nurse to include?

Nursing interventions

When a nurse notices the client is in pain and needs to learn to walk on crutches, which outcome identification is the priority?

Pain management

The nurse develops long-term and short-term outcomes for a patient admitted with asthma. Which of the following is an example of a long-term goal?

Patient returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

Which of the following outcomes is sufficiently measurable?

Patient will tolerate a full fluid diet with no complaints of nausea by 12/15/2011"

Which of the following is a correctly written nursing intervention? Select all that apply.

Provide 5 to 6 small meals daily. • Reposition the client from side to side every hour around the clock. • Provide opportunities for the client to express concerns and verbalize feelings.

A nurse identifies outcomes of care for the hospitalized, postoperative client primarily to

Provide individualized care

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

Psychomotor

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

Psychomotor

Increasingly, healthcare institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes which of the following?

Reduction in the time spent on care planning

Patient education in the care of a male patient with emphysema has focused on smoking cessation. As a result, nurses have prioritized the following outcome in his plan of care: "By 1/12/2011, patient will state that he no longer smokes." This outcome contains which of the following components of a measurable outcome? Select all that apply.

Subject • Verb • Performance criteria • Target time

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention?

Teach client how to splint abdominal incision when coughing and deep breathing.

Which intervention does the nurse recognize as a collaborative intervention?

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

The nurse recognizes that an example of a cognitive outcome is:

The client identifies three foods high in potassium by August 8.

Which of the following client outcomes best describes the parameter for achieving the outcome?

The client will consume a 2,400 calorie diet, with three meals and two snacks, starting tomorrow.

The nurse is caring for a client with a nursing diagnosis of Anxiety related to decreased ability to cope with new diagnosis of breast cancer. Which error has the nurse made if an expected outcome is "The client will state, 'I am coping better' by May 12?"

The nurse used the etiology to formulate the outcome.

A nurse is giving post-operative care to a client after knee arthroplasty. Which of the following is a possible short-term goal for this client?

To ambulate the client to a bedside chair

Student nurses are providing basic care for patients on a medical-surgical unit. One young student nurse is assigned to care for a 78 year old male with a diagnosis of AIDS related pneumonia. The man was admitted early that morning and is in need of a bath and a shampoo. He is homeless and undernourished. The student tells her instructor that she does not want to care for this patient. What key component of critical thinking has this student yet to incorporate into her practice?

Withholding judgement

The nurse assigned to care for a client has established client outcomes and outcome criteria. After completing this task, which of the following would the nurse do next?

Write a client plan of care.

Which of the following is a correctly written client goal? Select all that apply.

• The client will identify five low-sodium foods by October 9. • The client will rate pain as a 3 or less on a 10-point scale by 5 pm today. • The client will eat at least 75% of all meals by May 5.

Which of the following reflect planning? Select all that apply.

• The nurse decides to assist the client with ambulation in the hallway twice a shift. • The nurse seeks input from the client and family regarding acceptable non-pharmacological pain management strategies. • The nurse considers the developmental level of the client when selecting teaching materials.

Mr. Hill is scheduled to be fitted with a prosthesis following the loss of his nondominant hand in a farm accident several weeks earlier. Nurses have documented the following outcome during this stage of his care: "After attending an educational session, patient will demonstrate correct technique for applying his prosthesis." Which of Mr. Hill's following statements would signal a need to amend this outcome?

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

For which of the following patients would a standardized plan of care most likely be appropriate?

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

A nurse caring for a patient 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 standardized care plan

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

Demonstrates coughing exercises at next session

A nurse is demonstrating foley catheter care to a client. Which type of nursing intervention does this best represent?

Educational

A client is rehabilitating from a fractured right leg. She is learning to walk on crutches. Together, the client and the nurse have established a plan for the client to walk with a three-point gait for 20 feet by the next day. In outcome identification, what is this termed?

Establishing a client goal

A client is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes?

Family

The nurse formulates the following client outcome: "Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7." Which error has the nurse made?

Included more than one client behavior in the outcome

The nurse is prioritizing the client's nursing diagnoses. Which nursing diagnosis has the highest priority?

Ineffective Airway Clearance related to retention of secretions

The Nursing-Sensitive Outcomes Classification system organizes outcomes by

Measurement activities

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

In planning the care of a patient who has been diagnosed with asthma, the nurse has written the following outcome: "Patient will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2011." Why is this outcome inadequate?

The chosen verb is not observable or measurable.

The nurse is caring for a client with the nursing diagnosis, Disturbed Body Image related to decreased ability to cope with surgical removal of right breast AEB client refuses to look at surgical site and client statement, "I'm ugly. My husband will no longer find me desirable." The nurse recognizes that expected outcomes include:

The client will participate in caring for the surgical incision.

Which outcome is incorrect for the nursing diagnosis: Anxiety related to decreased ability to cope with new diagnosis of breast cancer.

The client will state "I am coping better" by May 12.

Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing patient outcomes?

The nurse expresses the patient outcome as a nursing intervention.

A patient's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the patient's surgery will have a significant impact on her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this patient?

Upon her admission to the hospital

For the postoperative client, which of the following nursing diagnoses will require outcome identification that could contribute to a maladaptive postoperative recovery?

Ineffective breathing patterns

Nurse L. is caring for a patient who has been newly diagnosed with diabetes. One of the outcomes that Nurse L. read on the patient's plan of care this morning was: "Patient will demonstrate correct technique for self-injecting insulin." The patient required insulin prior to his lunch and successfully drew up and administered his insulin while Nurse L. observed. How should Nurse L. follow up this observation?

Record an evaluative statement in the patient's plan of care.

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority?

Resolve the client's anxiety