Chapter 16: Outcome Identification and Planning

Which is an appropriate expected outcome for a client? -By the next clinic visit, client will report taking antihypertensive medication. -Client will ambulate safely with walker in the room within 3 days of physical therapy. -Client will perform complete ostomy care while bathing on the second postoperative day. -After attending sibling classes, client will be happy about a new infant and demonstrate feeding.

Client will ambulate safely with walker in the room within 3 days of physical therapy.

A broad, research-based practice recommendation that may or may not have been tested in clinical practice is: a guideline. an algorithm. an order set. a critical pathway.

a critical pathway

The nurse recognizes that identifying outcomes/goals must include: involvement of the nurse manager and other staff nurses. input from the health care provider. input from the multidisciplinary team. involvement of the client and family

involvement of the client and family

What are specific measurable and realistic statements of goal attainment? Outcomes Nursing interventions Nursing diagnoses Evaluations

outcomes

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? "What are your plans after discharge?" "You need to stop smoking for us to effectively combat this disease." "Please tell me your thoughts about treating this diagnosis." "Do you want to be discharged without treatment?"

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

Which guideline should the nurse follow when including interventions in a plan of care? -Date the nursing interventions when written and when the plan of care is reviewed. -Make sure each nursing intervention does not describe the action the nurse should perform. -Make sure the nursing interventions are unrelated to the original outcomes. -Make sure the attending health care provider approves of and signs the nursing interventions.

Date the nursing interventions when written and when the plan of care is reviewed.

These nursing diagnoses appear on a client's care plan. Place in the order in which the nurse will prioritize acting upon them. Use all options. 1Impaired Swallowing 2Risk for Impaired Skin Integrity 3Altered Body Image 4Fluid Volume Deficit

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

A computerized information system developed to classify client outcomes is the: International Classification of Diseases Clinical Care Classification System NANDA-International list Nursing Outcome Classification system

Nursing Outcome Classification system

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

Ongoing

A nurse is reviewing the plan of care for a client and notes: "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." The nurse should identify this statement as an example which element of nursing practice? Intervention Evaluation Outcome Nursing diagnosis

Outcome

A nurse is working with a client who is having a difficult time accepting a new diagnosis of type 2 diabetes. The nurse pulls up a chair next to the client's bed and holds the client's hand while listening to the client's story. What type of nursing intervention is the nurse engaging in? Coordinating Psychosocial Supportive Supervisory

Supportive

The nurse recognizes that an example of a cognitive outcome is: The client verbalizes increased confidence in testing glucose levels. The client identifies three foods high in potassium by August 8. The client accurately measures the radial pulse for 1 minute by February 2. The client demonstrates self-catheterization using clean technique by June 3.

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

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? Passive abduction with assistance The client performed active range of motion exercises only twice today but states a goal of 3 times per day tomorrow. 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. The client will perform range of motion exercises 3 times per day.

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.

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client? The client will demonstrate the correct use of a metered-dose inhaler. The client will ambulate 100 feet without supplementary oxygen or mobility aids. The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. The client will express an understanding of strategies for managing fatigue and shortness of breath.

The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath.

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 not made any error in writing the outcome. The nurse has omitted the defining characteristics. The outcome should indicate what the nurse will do. The nurse has omitted the time frame.

The nurse has omitted the time frame.

When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "The client will know how to self-administer prescribed bronchodilators using a nebulizer by 09/09/2020." Why is this outcome inadequate? -The statement expresses a client outcome as a nursing intervention. -The outcome is not observable or measurable. -The outcome does not specify the conditions in which it will be achieved. -The outcome is not related to an independent nursing action.

The outcome is not observable or measurable.

Which is an example of a psychomotor outcome? Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. The client's skin will remain smooth, moist, and without breakdown or ulceration. The client will verbalize understanding of the need to continue to take medications as prescribed. Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

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

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: ongoing planning. comprehensive planning. discharge planning. initial planning.

discharge planning.

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually -does not contain documented scientific rationales. -separates outcome criteria from the plan of care. -separates goal statements from the plan of care. -does not contain abbreviated nursing diagnoses.

does not contain documented scientific rationales

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: -identifies the unhealthy response preventing desired change. -suggests client goals to promote desired change. -identifies client strengths. -identifies factors causing undesirable response and preventing desired change.

identifies factors causing undesirable response and preventing desired change.

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? "Client tries using relaxation as a means to cope." "Client will identify one coping strategy to try by end of week." "Client will learn to cope more effectively." "Client will list positive coping strategies and use them."

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

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 drowsy after lunch. Client is normotensive. Client lipids are within range. Client reports no headache.

Client is normotensive

What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)? -Nurses do not carry out health care provider-initiated interventions. -Nurses are responsible for reminding health care providers to implement orders. -Nurses are not legally responsible for these interventions. -Nurses do carry out interventions in response to a health care provider's order.

Nurses do carry out interventions in response to a health care provider's order.

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? Process Outcome Structure Cost-effectiveness

Outcome

Which are characteristics of appropriate client outcome statements? Select all that apply. Broad in scope Specific Realistic Measurable Short-term

Specific Realistic Measurable

Which client outcome requires modification? -Within 2 days, client will describe two responses to firing of the internal defibrillator. -Client will correctly self-administer subcutaneous insulin before discharge. -By the end of instruction, client will know how to perform dressing changes. -Client will demonstrate safe transfers from bed to chair within 24 hours.

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

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns? "Leaning forward may help you to breathe better." "Do not practice pursed lip breathing, as this is a contraindication." "Running short distances can help you breathe better." "Take short and shallow breaths instead of deep breathing."

"Leaning forward may help you to breathe better."

Which outcome for a client with a new colostomy is written correctly? -The client will be able to care for stoma and cope with psychological loss by 3/29/20. -The client will know how to care for the stoma by 3/29/20. -The client will demonstrate proper care of the stoma by 3/29/20. -Explain to the client the proper care of the stoma by 3/29/20.

-The client will demonstrate proper care of the stoma by 3/29/20.

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? Guidelines An order set An algorithm A standardized care plan

A standardized care plan

A nurse designs a care plan to improve walking mobility in an older adult client. When the nurse encourages the client 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 Failing to update the written plan of care Beginning the plan without family to help Choosing actions that do not solve the problem

Developing the plan without client input

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

Psychomotor

For which client would a standardized plan of care most likely be appropriate? A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy A client who was admitted for shortness of breath and who has been diagnosed with pneumonia A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident

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

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. Encourage the client to join a therapy group. Document that the depression has resolved. Tell another nurse about this client statement.

Add the nursing diagnosis: Risk for Self-Harm.

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? Client will eat small meals of bland foods for 3 days. Client will identify the food that caused the condition within 3 hours. Client will maintain adequate hydration within 2 days. Client will have formed stools within 24 hours.

Client will have formed stools within 24 hours.

Which action should the nurse perform during the planning phase of the nursing process? Assess the client's overall health. Identify measurable goals or outcomes. Analyze the client's response to medicines. Identify the client's health-related problems.

Identify measurable goals or outcomes.

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 health care provider 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? Physical therapy will be consulted to assist the client with ambulation. The client will ambulate to the restroom 3 times this shift. The client will ambulate with the assistance of a walker without falling within the next 4 hours. The client will ambulate with the assistance of a walker sometime today.

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

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. asking the client for a pain rating reviewing the client's intraoperative record determining effectiveness of pain medication observing the client's ability to move in the bed checking the strength of pedal pulses

-observing the client's ability to move in the bed -checking the strength of pedal pulses -asking the client for a pain rating -reviewing the client's intraoperative record

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. After counseling, the client will describe two coping measures to deal with stress. The client will list the dangers of smoking and quit. By 4/5/20, the client will demonstrate how to care for a colostomy. 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. After counseling, the client will describe two coping measures to deal with stress. By 4/5/20, the client will demonstrate how to care for a colostomy.

Which outcome statements are in the cognitive realm? Select all that apply. Within 1 week after teaching, the client will list three benefits of quitting smoking. By 6/8/20, the client will describe a meal plan that is high in fiber. By 6/8/20, the client will correctly demonstrate self-injecting insulin. After viewing the film, the client will verbalize four benefits of daily exercise. By 6/8/20, the client will correctly demonstrate ambulating with a walker.

-Within 1 week after teaching, the client will list three benefits of quitting smoking. -By 6/8/20, the client will describe a meal plan that is high in fiber. -After viewing the film, the client will verbalize four benefits of daily exercise.

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 plan designed to support the client physically A plan made in conjunction with the hospital's ethics committee A plan with problems that are easily solved A plan derived from a consensus of opinions of all staff members

A plan designed to support the client physically

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 increase protein intake in small frequent meals. Client will use oxygen by nasal cannula when short of breath. Client will consistently perform pulmonary exercises. Client will alternate rest periods with exercise throughout the day.

Client will alternate rest periods with exercise throughout the day.

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem? Client will not leave the premises without a caregiver. Client will consistently return to the police station when lost. Client will identify landmarks that indicate location of home. Client will wear an ID bracelet with name and contact information.

Client will not leave the premises without a caregiver.

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. Reassess in 4 hours and document the findings. Provide oral pain medication before ambulation. Promote oral fluid intake between meals.

Encourage hourly use of the incentive spirometer.

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. Expect to modify the plan significantly. Include the rationale for the interventions. Identify the appropriate nursing diagnoses.

Individualize the plan to the client.

A nurse is writing outcomes for a client who is scheduled to ambulate following hip replacement surgery. Which is a correctly written outcome for this client? The nurse will help the client ambulate the length of the hallway once a day. The client will become mobile within a 24-hour period. Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. Offer to help the client walk the length of the hallway each day.

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

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? Set priorities using client care standards. Consult with another nurse. Follow institutional guidelines. Seek research about the disorder.

Seek research about the disorder.

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. -Answer the client's questions about diet alterations, and then evaluate understanding. -Ask the client's learning style, then teach diet information using that style. -Present the client with videos and books about diet changes that reduce inflammation.

Start from client's knowledge, teach about diet modifications, and check for learning.

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? -By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. -The client will understand the effects of smoking related to heart disease. -By 08/02, the client will state three therapeutic methods of reducing stress. -By 8/02, the client will state when to notify the health care provider after discharge

The client will understand the effects of smoking related to heart disease.

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? Updating the diet orders in the client's plan of care Adding the diagnosis "Altered Nutrition, Less Than Required" Posting the sign "NPO after midnight" over the bed Obtaining written consent for the diagnostic procedure

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