PrepU Ch16 outcome identification

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." -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 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 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."

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." -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.

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 -Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. An algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions. A guideline is a statement by which to determine a course of action. An order set is a predetermined set of orders by a prescriber that dictates care of the client.

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. -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 is caring for a client admitted for bowel obstruction, which now has been resolved. The client has an order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply.

Auscultate for bowel sounds. Begin feedings with clear broth. Consult with a dietitian regarding appropriate foods. -Feedings should begin slowly with clear liquids as the first food. Immediately resuming a standard diet after a period of having nothing by mouth is likely to result in gastrointestinal distress. It is appropriate for the nurse to monitor bowel sounds and to consult with the dietician.

The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority?

By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms -Safety is a top client priority. About half of all clients with alcohol addiction may develop alcohol withdrawal, which can lead to delirium tremens (DTs) with an estimated 15% fatality rate. The client who can recognize the need for tranquilizers can be treated to avoid DTs. It is unrealistic to expect the client to begin a 12-step program only 48 hours after being admitted in withdrawal. Similarly, starting therapy the day after admission would be premature. There is no way of knowing if a 3-day admission is sufficient for the client's needs.

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. -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.

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? -By the next clinic visit, client will report taking antihypertensive medication. 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. Client will perform complete ostomy care while bathing on the second postoperative day.

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.

A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "Impaired Swallowing." Which expected client outcome is most effective?

Client will use chin tuck and double swallow for each bite. -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 actions will improve oral intake by the client with dysphagia, the most effective is a chin tuck and double swallow. These actions reduce the risk of aspiration and aid the movement of food down the esophagus.

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. -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 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 -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.

Which outcome for a client with a new colostomy is written correctly?

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.

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. -Standardized plans of care are written by a group of nurses who are experts in a given area of practice (e.g., obstetrics, rehabilitation, orthopedics). The plans are written for a client population with a specific medical diagnosis (e.g., total hip replacement, pressure injury, vaginal delivery, coronary artery bypass surgery). These experts identify the most common nursing diagnoses for this client population and write the goals and interventions usually necessary to resolve the problem. Each time a standardized plan of care is used, it must be individualized for a specific client. The danger of a standardized plan of care lies in the fact that it may not fit a specific client. Nurses must make judgments as to the degree to which standardized plans should be modified or whether they should not be used in individual cases. With a standardized plan of care, the most common nursing diagnoses have already been identified. Rationales are typically not included on clinical plans of care.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis. -Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a health care provider's order. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. They are not performed to diagnose any problem, medical or otherwise, but to help prevent or resolve a problem identified in a nursing diagnosis and thereby to achieve the related expected client outcome.

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

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 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?

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.

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?

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 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. -Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. "Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse" has all of these characteristics. "The nurse will help the client ambulate the length of the hallway once a day" is not specific in whether assistance is required, is not timebound, and is not client-centered, in that the nurse is the subject of the sentence, not the client. "Offer to help the client walk the length of the hallway each day" is a nursing intervention, not a client outcome. "The client will become mobile within a 24-hour period" is not specific or measurable.

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

Psychomotor - Psychomotor interventions include activities such as positioning, inserting, and applying. A psychosocial intervention focuses on supporting, exploring, and encouraging. Maintenance and surveillance are monitoring 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?

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.

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 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?

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.

Which is an example of a nurse-initiated intervention?

Teach the client how to splint an abdominal incision when coughing and deep breathing. -A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nurse-initiated interventions, such as teaching, do not require a health care provider's order. A health care provider's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

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? 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 demonstrate a daily meal plan to reduce cholesterol in the diet. 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. -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 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. -Outcomes are client-centered, use action verbs, identify measurable performance criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted. Defining characteristics are a component of the nursing diagnosis, not a client outcome. Because outcomes are client-centered, they describe what the client will do, not what the nurse will do.

A client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a nonblanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take?

The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour. -An observation of a reddened area on a client's skin that doesn't blanch after pressure is relieved is characteristic of a first-degree pressure injury. This indicates that the current nursing intervention of turning and repositioning the client every 2 hours to prevent impaired skin integrity is inadequate. The client's nursing care plan needs to be revised to reflect the new assessment finding of an actual pressure injury. Additionally, new nursing interventions need to be implemented to turn and reposition the client hourly to relieve the pressure on the trochanter ulcer and prevent the formation of new pressure injuries. Repositioning the client to the client's back, documenting the intervention, reassessing the client's right trochanter in 2 hours, and documenting the condition of the skin in the medical record all fail to update the nursing care plan and revise the interventions to a more frequent turning and repositioning schedule.

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:

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.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

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.

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. -In clinical settings, nurses may use rationales to illustrate research findings or support controversial approaches to problems. These rationales are not typically included in the clinical nursing care plan. The process of developing both clinical and instructional nursing care plans would follow similar procedures in addressing the other aspects of the nursing care planning process.

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:

identifies factors causing undesirable response and preventing desired change. -The cause of the client health problem is referred to as the etiology. The problem statement of the nursing diagnosis suggests the client goals, and the cause of the problem (etiology) suggests the nursing interventions. Identifying the unhealthy response preventing desired change would occur during the evaluation phase of the nursing process. Client strengths are identified during the nursing diagnosis phase.

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention -A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance client goals and outcomes. Nursing diagnoses are statements of the client's actual or potential health problems that the nurse is seeking to address through interventions and are the overarching driver of goal-setting, care planning, and interventions. Evaluation, the final phase of the nursing process, involves assessing the client's response to interventions on an ongoing basis and making any necessary adjustments and changes to the nursing care plan.

The nurse recognizes that identifying outcomes/goals must include:

involvement of the client and family. -One of the most important considerations in writing outcomes is to encourage clients and families to be as involved in goal development as their abilities and interests permit. The more involved they are, the greater the probability that the goals will be achieved. Client-centered care focuses on the client needs and desires and thus would not require input from the health care provider, the nurse manager, or multidisciplinary team.

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?

ongoing -Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, and the chief purpose is to keep the plan up-to-date. Initial planning is developed by the nurse who performs the admission nursing history and the physical assessment. Discharge planning prepares the client for discharge from the health care setting. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning.