Fundamentals Chapter 8: Outcome Identification and Planning

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 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.

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

Autonomous, clinical judgment, client outcomes

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.

The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client?

Comfort the client and family.

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?

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

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.

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

The need to feel good about oneself

Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent?

Verb

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

Client education in the care of a male client with emphysema has focused on smoking cessation. As a result, nurses have prioritized the following outcome in his plan of care: "By 1/12/2016, client will state that he no longer smokes." This outcome contains which components of a measurable outcome? Select all that apply. 1. subject 2. verb 3. conditions 4. performance criteria 5. Target time

1, 2, 4, 5

Which type of care plan is most likely to enable the nurse to take a holistic view of the client's situation?

Concept map care plan

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.

Which is a common error nurses make when writing client outcomes?

Expressing the client outcome as a nursing intervention

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

Ongoing planning

Which is an example of a long-term outcome for a client with asthma?

The client will return home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.

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.

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

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome?

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

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."

A nurse is developing a care plan for a client with a stroke and is including surveillance interventions. What would the nurse most likely include?

Monitoring blood pressure

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

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 normotensive.

Which is an appropriate expected outcome for a client?

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

Which action should the nurse perform during the planning phase of the nursing process?

Identify measurable goals or 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?

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

What common problem is related to outcome identification and planning?

Failing to involve the client in the planning process

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.

In planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2016." Why is this outcome inadequate?

The chosen verb is not observable or measurable.

A nurse is preparing to write client outcomes for a plan of care. Which verb would be least appropriate to use when writing the outcomes?

Understands

The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply. 1. Demonstrate the correct use of crutches to the client prior to discharge. 2. The client will know how to dress the wound after receiving a demonstration. 3. After attending an infant care class, the client will correctly demonstrate the procedure for bathing the newborn. 4. By 4/5/20, the client will demonstrate how to care for a colostomy. 5. The client will list the dangers of smoking and quit. 6. After counseling, the client will describe two coping measures to deal with stress.

3, 4, 6

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

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family.

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