Chapter 14: Outcome and Planning

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "Client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

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?

"Please tell me your thoughts about treating this diagnosis."

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."

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?

Add the nursing diagnosis: Risk for Self-Harm.

A nurse is developing the postoperative plan of care for a client admitted with a fractured hip who has undergone surgery to repair it. Which intervention would the nurse identify as a nurse-initiated intervention? Select all that apply.

Assess the client's pain level every 2 hours. Turn the client every 2 hours per turning schedule. Teach the client how to perform relaxation as a pain relief strategy.

A nurse administers clonidine according to the standardized plan of care for a client admitted with hypertension. Which assessment information deviates from the expected client outcome for the first 24 hours and requires nursing intervention?

Client gains 1 kg (2.2 lb) in 1 day

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?

Client is normal tensive.

The nurse develops long-term and short-term outcomes for a client admitted with asthma. What is an example of a long-term goal?

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

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?

Client will have formed stools within 24 hours.

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?

Encourage hourly use of the incentive spirometer.

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.

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do?

Individualize the plan to the client.

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

Make recommendations for revising the plan of care.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?

Nurses do carry out interventions in response to a physician's order.

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

Ongoing planning

A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this client?

Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.

A nurse has identified on the plan of care for a client a nursing diagnosis of "Anxiety related to concerns about cancer treatment as evidenced by client's statement." One of the interventions that the nurse writes on the plan of care is to encourage the client to verbalize his feelings about the diagnosis and its effect on his quality of life. The nurse has identified which type of nursing intervention?

Psychosocial

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

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

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.

The nurse is planning the care of a client. What behaviors reflect planning? Select all that apply.

The nurse decides to assist the client with ambulation in the hallway twice per shift. The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. The nurse considers the developmental level of the client when selecting education materials.

The nurse is developing outcomes for a problem statement. What would the nurse do to make the outcomes more achievable?

The nurse encourages the client and family to be involved in the development of outcomes.

Nurses make common errors in the identification and development of outcomes. What is a common error made when writing client outcomes?

The nurse expresses the client outcome as a nursing intervention.

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.

Which of the following is categorized as a psychomotor outcome?

Within 2 days of education, the client's wife will demonstrate abdominal dressing change.

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 standardized care plan

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using:

assessment skills.

Which group of terms best describes a nurse-initiated intervention?

autonomous, clinical judgment, client outcomes

A nurse plans a series of muscle strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. Which action by the nurse may have led to failure to meet the outcome?

choosing actions that do not solve the problem

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged to implement the new strategies for ambulation, the client refuses to try and tells the nurse, "I find it easier to use a wheelchair." What action by the nurse may have led to failure to meet the outcome?

developing the plan without client input

A nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The nurse then uses the data to update the client plan of care. What are these actions considered?

ongoing planning

Increasingly, health care institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes:

reduction in the time spent on care planning.

A resident of a long-term care facility refuses to eat until she has had her hair combed and her makeup applied. In this case, what client need should have priority?

the need to feel good about oneself

What is the primary purpose of the outcome identification and planning step of the nursing process?

to design a plan of care for and with the client

A client is required to be n.p.o. 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?

updating the diet orders in the client's plan of care