Outcome Identification and Planning - Chapter 17 - PrepU
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? a) structure b) process c) cost-effectiveness d) outcome
d) outcome. An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the expected client outcome. A broad view of evaluation in health care includes three approaches, directed toward structure, process, and outcome, depending on the focus of evaluation and the criteria or standards being used. Process/implementation evaluation determines whether program activities have been implemented as intended. Cost-effectiveness evaluation compares the relative costs to the outcomes (effects) of two or more courses of action. Structure evaluation assesses the effectiveness of various health care structures.
A client's diagnosis of breast cancer necessitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on the client's activities of daily living (ADLs) during the period of recovery. When should the nurse begin discharge planning to address this client's ADLs? a) On the client's admission to the hospital b) Once the client is admitted to the nursing unit from postanesthetic recovery c) Once the client has received a discharge order d) As soon as possible after the client's surgery
a) On the client's admission to the hospital. Discharge planning should begin when a client is admitted for treatment. All the other times listed are too late and are not consistent with a client who is able to understand the process of the hospitalization.
The nurse is selecting interventions after gathering and analyzing client data. Interventions that the nurse includes will meet what criterion? a) Time-specific b) Aligned with a goal c) Based on collaboration with the care provider d) Multidisciplinary
b) Aligned with a goal. Nursing interventions must be specifically designed to meet the identified goal. These are grounded in the scope of nursing practice so they may not require collaboration with other disciplines. Goals and outcomes should be time-specific but interventions may not always be.
A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? a) "Client will identify one coping strategy to try by end of week." b) "Client tries using relaxation as a means to cope." c) "Client will learn to cope more effectively." d) "Client will list positive coping strategies and use them."
a) "Client will identify one coping strategy to try by end of week." An appropriate outcome includes the client, an action verb, the circumstances by which the outcome is to be achieved, the performance criteria, and time frame. Identifying one coping strategy to try by the end of the week meets these criteria. The statement about the client learning to cope more effectively is not measurable. The statement about listing positive coping strategies and using them includes more than one behavior to evaluate, making it difficult to evaluate achievement. The statement about using relaxation is vague and not really measurable.
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? a) "Nursing interventions are pretty much the same for clients that have the same medical diagnosis." b) "Nursing interventions are selected based on the etiology in the nursing diagnosis and must be compatible with other therapies planned for the client." c) "Nursing interventions should be consistent with standards of nursing care and research findings." d) "The client's developmental level, values, beliefs, and cultural and psychosocial background should be considered when selecting nursing interventions."
a) "Nursing interventions are pretty much the same for clients that have the same medical diagnosis." Nursing interventions should be based on the etiology in the nursing diagnosis, be compatible with other planned therapies, be consistent with standards of care and research, and individualized for the client.
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) A plan designed to support the client physically b) A plan derived from a consensus of opinions of all staff members c) A plan with problems that are easily solved d) A plan made in conjunction with the hospital's ethics committee
a) A plan designed to support the client physically. An unconscious client who is unable to provide input into outcome identification depends on the nurse to make informed choices to support the client physically. This care plan would treat any life-threatening situations and act to prevent the development of unhealthy physical consequences. The nurse is in the best position to determine client needs and would not seek the opinion of all staff members or the ethics committee. The care plan would deal with all problems, not just those that are easily solved.
Which outcome is sufficiently measurable? a) Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020. b) Client will maintain adequate intake with no reports of nausea by 12/15/2020. c) Client will progress from clear fluid diet to full fluid diet without experiencing nausea. d) Increase client's diet from clear fluids to full fluids by 12/15/2020.
a) Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020. A fully measurable outcome should include a subject, verb, conditions, performance criteria, and target time (though not every outcome requires each parameter). Only the outcome "Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020" includes all appropriate components. The outcome "Client will progress from clear fluid diet to full fluid diet without experiencing nausea" lacks a target time. The outcome "Increase client's diet from clear fluids to full fluids by 12/15/2016" expresses the outcome as a nursing intervention. The outcome "Client will maintain adequate intake with no reports of nausea by 12/15/2016" does not define the performance criteria sufficiently, because "adequate intake" is an imprecise term.
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? a) Developing the plan without client input b) Beginning the plan without family to help c) Failing to update the written plan of care d) Choosing actions that do not solve the problem
a) Developing the plan without client input. Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. There is no indication that the nurse included strategies in the plan of care that did not solve the client's problem. There is no evidence that the care plan needed to be updated or that the nurse failed to do so. Although family support can be important to achieving client outcomes, not every client outcome requires family support.
A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: temperature, 98.24°F (36.8°C) sublingual; heart rate, 95 beats/min; respiratory rate, 20 breaths/min; blood pressure, 130/65 mm Hg. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. Which order is the nurse likely to request first for the client? a) Opioid analgesic to treat pain b) Septic workup due to blood pressure and heart rate elevation c) Isolation for suspected respiratory illness d) Acetaminophen to treat pain and fever
a) Opioid analgesic to treat pain. A sickle cell crisis is an extremely painful event. Most clients with sickle cell disease have an individualized opioid plan that will help them to receive opioids in an expedited manner when they present in crisis. The slight elevations in the client's blood pressure and heart rate are likely secondary to pain, not sepsis. There is no evidence of respiratory illness based on the information given. Acetaminophen is not strong enough to treat this client's pain; furthermore, the client does not have a fever.
A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client? a) The client will ambulate with assistance by the nurse to a bedside chair. b) The client will return to performing activities of daily living. c) The client will walk 1 mile briskly five times per week. d) The client will not undergo repeat surgery.
a) The client will ambulate with assistance by the nurse to a bedside chair. The short-term goal in this case is to help the client ambulate to the bedside chair. The other goals, like helping the client return to activities of daily living, to maintain a healthy and active lifestyle, and to prevent repeat surgery are long-term goals and may take weeks or months to achieve. On the other hand, short-term goals can be achieved in a day or a week.
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? a) Supportive b) Psychosocial c) Coordinating d) Supervisory
a) supportive Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems. Coordinating interventions involve many different activities, such acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall health care.
A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? a) Client will identify the food that caused the condition within 3 hours. b) Client will have formed stools within 24 hours. c) Client will eat small meals of bland foods for 3 days. d) Client will maintain adequate hydration within 2 days.
b) Client will have formed stools within 24 hours. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal.
What is true of nursing responsibilities with regard to a health care provider-initiated intervention (health care provider's order)? a) Nurses are not legally responsible for these interventions. b) Nurses do carry out interventions in response to a health care provider's order. c) Nurses are responsible for reminding health care providers to implement orders. d) Nurses do not carry out health care provider-initiated interventions.
b) Nurses do carry out interventions in response to a health care provider's order. A health care provider-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the health care provider and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding health care providers to implement orders, nurses may request a health care provider to implement an order or question an existing order by the health care provider if the nurse believes it is in the client's best interests.
A computerized information system developed to classify client outcomes is the: a) NANDA-International list b) Nursing Outcome Classification system c) International Classification of Diseases d) Clinical Care Classification System
b) Nursing Outcome Classification system. The Nursing Outcome Classification system organizes outcomes according to categories, classes, labels, indicators, and measurement activities. The remaining options do not classify client outcomes. NANDA-International is an organization that develops standardized terminology for nursing diagnosis to ensure client safety and improve client outcomes. The International Classification of Diseases is a classification system for classifying diseases according to diagnosis codes. The Clinical Care Classification System is a standardized system of codes used to label discrete components of nursing practice.
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? a) Nursing diagnosis b) Outcome c) Intervention d) Evaluation
b) Outcome. This statement is an example of an expected client outcome. Outcomes answer the questions who (the client), what actions (verbalizes), under what circumstances (to the staff), how well (accurately), and when (before discharge). A nursing diagnosis, which identifies a client health problem, would include a diagnostic label, related factors, and defining characteristics. An intervention would reflect an action or treatment the nurse performs to promote client outcomes. An evaluation is not a statement but rather a process of assessing the client's response to nursing interventions.
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? a) Present the client with videos and books about diet changes that reduce inflammation. b) Start from client's knowledge, teach about diet modifications, and check for learning. c) Ask the client's learning style, then teach diet information using that style. d) Answer the client's questions about diet alterations, and then evaluate understanding.
b) Start from client's knowledge, teach about diet modifications, and check for learning. The nursing interventions written to assist a client to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what assessments need to be made and what nursing interventions, including teaching, counseling, and advocacy, need to be done. They should also include evaluation of the outcome of the intervention. "Start from client's knowledge, teach about diet modifications, and check for learning" provides the most comprehensive intervention for this client, as it includes assessment of the client's current level of knowledge, teaching, and evaluation of the teaching. None of the other answer options includes all three of these elements.
Which outcome for a client with a new colostomy is written correctly? a) The client will be able to care for stoma and cope with psychological loss by 3/29/20. b) The client will demonstrate proper care of the stoma by 3/29/20. c) Explain to the client the proper care of the stoma by 3/29/20. d) The client will know how to care for the stoma by 3/29/20.
b) The client will demonstrate proper care of the stoma by 3/29/20. Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement.
What behaviors reflect planning? Select all that apply. a) The nurse assists the client with bathing, grooming, and dressing. b) The nurse decides to assist the client with ambulation in the hallway twice per shift. c) The nurse considers the developmental level of the client when selecting education materials. d) The nurse assesses the client's usual sleep routine. e) The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies.
b) The nurse decides to assist the client with ambulation in the hallway twice per shift. c) The nurse considers the developmental level of the client when selecting education materials. e) The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. Planning involves selecting evidence-based nursing interventions that will best address a client's problems as specified in the nursing diagnoses and thereby achieve the client's planned outcomes. Deciding to assist the client with ambulation, seeking input from the client and family on pain management, and considering a client's developmental level when selecting educational materials are all actions involving the nurse selecting interventions to best meet the client's needs. Assessing the client's usual sleep routine is an example of the assessment phase of the nursing process, not the planning phase. Assisting the client with bathing, grooming, and dressing is an example of the implementation phase of the nursing process, not the planning phase.
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? a) Posting the sign "NPO after midnight" over the bed b) Updating the diet orders in the client's plan of care c) Obtaining written consent for the diagnostic procedure d) Adding the diagnosis "Altered Nutrition, Less Than Required"
b) Updating the diet orders in the client's plan of care. The plan of care communicates three different types of nursing care: care related to meeting basic human needs, care related to nursing diagnoses, and care that must be coordinated with medical and interdisciplinary providers. Nutrition is a basic human need. The temporary need to withhold food and fluid should be documented in the record. The other options are not the best, most direct methods for conveying this information to all who may need it.
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? a) "Do you want to be discharged without treatment?" b) "You need to stop smoking for us to effectively combat this disease." c) "Please tell me your thoughts about treating this diagnosis." d) "What are your plans after discharge?"
c) "Please tell me your thoughts about treating this diagnosis." In the planning stage of the nursing process, the nurse must focus on the client's interests and preferences, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.
Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? a) Interrupted Breastfeeding b) Ineffective Thermoregulation c) Altered Gas Exchange d) Impaired Parenting
c) Altered Gas Exchange. Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, circulation, or safety issues such as threats of self-harm. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. Lack of surfactant interferes with lung expansion and can reduce oxygenation in premature infants. Breastfeeding and temperature regulation are of lower importance than oxygenation. Parenting skills may be promoted when parents visit high-risk infants in the nursery.
Which is an appropriate expected outcome for a client? a) By the next clinic visit, client will report taking antihypertensive medication. b) After attending sibling classes, client will be happy about a new infant and demonstrate feeding. c) Client will ambulate safely with walker in the room within 3 days of physical therapy. d) Client will perform complete ostomy care while bathing on the second postoperative day.
c) Client will ambulate safely with walker in the room within 3 days of physical therapy. Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy meets all of these criteria. "After attending sibling classes, client will be happy about a new infant and demonstrate feeding" is incorrect because it includes more than one client behavior, one of which is not observable or measurable ("be happy"), does not include performance criteria related to how well the client is to demonstrate feeding, and has a vague time frame ("after attending sibling classes"). "By the next clinic visit, client will report taking antihypertensive medication" lacks specificity regarding how often the client should take the medication. "Client will perform complete ostomy care while bathing on the second postoperative day" is likely not attainable within the time frame specified and lacks specificity regarding care the client will provide, making it difficult for the nurse to measure the client's success.
Which guideline should the nurse follow when including interventions in a plan of care? a) Make sure the attending health care provider approves of and signs the nursing interventions. b) Make sure the nursing interventions are unrelated to the original outcomes. c) Date the nursing interventions when written and when the plan of care is reviewed. d) Make sure each nursing intervention does not describe the action the nurse should perform.
c) Date the nursing interventions when written and when the plan of care is reviewed. Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. Interventions should contain the date, a verb (action to be performed), the subject (who is to do it), and a descriptive phrase (how, when, where, how often, how long, or how much). The interventions should be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The health care provider does not approve and sign the interventions, because they are nursing interventions.
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? a) Reassess in 4 hours and document the findings. b) Promote oral fluid intake between meals. c) Encourage hourly use of the incentive spirometer. d) Provide oral pain medication before ambulation
c) Encourage hourly use of the incentive spirometer. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions.
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? a) Consult with another nurse. b) Set priorities using client care standards. c) Seek research about the disorder. d) Follow institutional guidelines.
c) Seek research about the disorder. While each option is appropriate, it is crucial to find research to support the plan before establishing priorities. The nurse planning care uses clinical reasoning to set priorities that incorporate standards and agency policies, identify and record expected client outcomes, select evidence-based nursing interventions, and record the plan of care.
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? a) The client will perform range of motion exercises 3 times per day. b) Passive abduction with assistance c) 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. d) The client performed active range of motion exercises only twice today but states a goal of 3 times per day tomorrow.
c) 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. Documentation should be specific. The evaluation is a form of communication with the multidisciplinary health care team that indicates how the client is progressing in meeting expected outcomes. The most detailed documentation of evaluation is the one that provides a numerical measure of the client's range of motion, along with the specific plan for continued evaluation. The remaining options are too general and vague while lacking accountability and stemming from the client perspective.
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: a) past medical history b) support system c) condition d) medical orders
c) condition. Because a person's condition changes, priorities change. Priorities are based on information collected during reassessment after recovery and assignment to the acute care setting. As the client heals these priorities can shift rapidly. The client's support system would have more of an impact on priorities of care once the client is being discharged to home, not while the client is in the acute care setting immediately after surgery. Both the client's medical orders and the client's nursing priorities change in response to the client's condition, rather than in response to one another. The client's past medical history, which doesn't change, is less likely to affect the nursing priorities of the client after surgery than the client's condition, which does change.
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? a) Encourage the client to join a therapy group. b) Tell another nurse about this client statement. c) Document that the depression has resolved. d) Add the nursing diagnosis: Risk for Self-Harm.
d) Add the nursing diagnosis: Risk for Self-Harm. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates risk for self-harm, not resolution of the depression. The nurse will perform additional assessment and add the new nursing diagnosis to the care plan. Changing the care plan to incorporate this new data makes it the most effective for treating the client. Telling another nurse could assist in treatment, but is less formal and less effective, because the entire team needs access to this information. While group therapy may provide help, it does not address the client's current mental health status related to self-harm.
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? a) Client reports no headache. b) Client is drowsy after lunch. c) Client lipids are within range. d) Client is normotensive.
d) Client is normotensive. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 and 120/80 mm Hg. The other options do not directly indicate successful control of hypertension.
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? a) By 08/02, the client will state three therapeutic methods of reducing stress. b) By 8/02, the client will state when to notify the health care provider after discharge c) By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. d) The client will understand the effects of smoking related to heart disease.
d) The client will understand the effects of smoking related to heart disease. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable. The verbs in the distractors are all measurable. The correct response has a goal that the nurse will be unable to measure.
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: a) initial planning. b) comprehensive planning. c) ongoing planning. d) discharge planning
d) discharge planning. Discharge planning begins at the time of admission with the nurse teaching the client and family specific skills necessary for self-care behaviors in the home. Comprehensive planning occurs from time of admission to time of discharge and includes initial, ongoing, and discharge planning. Initial planning is done at time of admission based on the nurse's admission assessment. Ongoing planning is conducted by any nurse caring for the client throughout the nurse-client relationship.