Chapter 18: Evaluating

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" "Inadequate skills" "Great response" "Extremely well-mannered"

"Demonstrated steps"

"The levels of performance accepted by and expected of nursing staff or other health team members" defines: 1. standards. 2. evaluation. 3. criteria. 4. evidence-based practice.

1. standards.

One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated? 1. throughout the client's hospital admission 2. during the first home health care visit 3. once the primary care physician has written a discharge order 4. when the client is discharged

1. throughout the client's hospital admission

Which statement related to the evaluation of outcome attainment for a client is correct? 1. Celebrating outcome achievement with a client often interferes with attainment of future goals. 2. The nurse should initially evaluate the plan of care at the time of the client's discharge. 3. Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria. 4. Evaluation of the client's attainment of outcome goals is determined by the nurse and physician.

3. Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria.

The nurse performs discharge teaching for a client. How would the nurse best evaluate the effectiveness of the discharge teaching?

Ask the client to repeat back to the nurse how care will be conducted at home.

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 Devising a plan for the client to practice anti-anxiety exercises at home Collecting data about the client's history with anxiety Assigning the client a new nursing diagnosis based on the client's controlled anxiety

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

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

"The client will verbalize appropriate cast care on discharge" represents which type of outcome?

Cognitive

Which action should the nurse take during the evaluation phase of the nursing process? Provide the client with a follow-up appointment after discharge. Have the client give input into plan of care upon admission. Document reassessment of pain after medication administration. Discontinue the indwelling urinary catheter per the provider's order.

Document reassessment of pain after medication administration.

The nurse is reassessing a client with leukemia who has received several packed red blood cell transfusions over the past week. Which question should the nurse ask the client to evaluate the treatment?

Have you had any fevers?

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

Nurses

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

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?

Quality assurance

Which action should the nurse perform in the evaluation phase? Record interventions. Set priorities for care. Revise the plan of care. Carry out treatment procedures.

Revise the plan of care.

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

Which are cognitive client outcomes? Select all that apply. The client describes how to perform progressive muscle relaxation. The client correctly ambulates with a walker. The client identifies signs and symptoms of hypoglycemia. The client reports cycling 30 minutes three times each week. The client lists the side effects of digoxin.

The client lists the side effects of digoxin. The client describes how to perform progressive muscle relaxation. The client identifies signs and symptoms of hypoglycemia.

Which nursing action reflects evaluation? The nurse performs colostomy irrigation. The nurse sets an anxiety level of 3 or less with the client. The nurse identifies that the client has wound drainage. The nurse assesses the client's response to pain medication.

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

Which characteristic is the most important indicator of high-quality nursing practice? The nurse considers the individual needs of clients. The nurse follows the policies and procedures of the institution. The nurse is organized and efficient in client care. The nurse takes measures to ensure accurate medication administration.

The nurse considers the individual needs of clients.

Which purpose of the evaluation phase of the nursing process is a priority during client care? To limit assessment to only the beginning phase of the nursing process To provide basis for the revision of plan of care To examine the client's behavioral response to the care received To appraise the collaboration of the client and family

To examine the client's behavioral response to the care received