139 Chapter 19 Questions

11. A nurse in a community health center has been having regular meetings with a client who wants to stop smoking. Which outcome decision option should the nurse document if the client has not smoked for 7 months? A. Outcome met B. Outcome partially met C. Outcome not met D. Outcome inappropriate

A Rationale: After data have been collected and interpreted to determine client outcome achievement, the nurse makes and documents a judgment summarizing the findings. The three decision options are met, partially met, and not met. In this case, the nurse's judgment should be that the client has met the expected outcome of smoking cessation. The nurse would not document the term "outcome inappropriate" but rather "outcome not met." Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 501-503

3. Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 ft (30 m) without the use of mobility aids by 12DEC." Several nurses have evaluated the client's progression towards this outcome at various points during care. Which evaluative statement is most appropriate? A. "12DEC - Outcome partially met. Client ambulated 75 ft (22.5 m) without the use of mobility aids" B. "12DEC - Outcome unmet. Client's ambulation remains inadequate." C. "12DEC - Outcome met, but with the use of a quad cane to assist ambulation." D. "12DEC - Outcome met."

A Rationale: An evaluative statement should include both the decision about how well the outcome was met along with data that support this decision. Characterizing the client's ambulation as "inadequate" is not sufficiently precise. Stating that this outcome was met with the use of a cane contradicts the original terms of the outcome. The statement "outcome met" is not descriptive with data that supports the outcome. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 502-503

24. The nurse is giving a shift report to the oncoming nurse who will be caring for a client currently receiving peritoneal dialysis in the client's room. The oncoming nurse states, "I have never taken care of a client receiving peritoneal dialysis. Would you give me the basics so I know what to do?" Which standard for establishing and sustaining healthy work environments is the oncoming nurse breaching? A. Appropriate staffing B. Effective decision making C. True collaboration D. Skilled communication

A Rationale: Appropriate staffing ensures that client needs are effectively matched with nurse competencies. In this scenario, the nurse is ill-prepared to care for the client. The nurse needs structured training to learn about the nursing care for the client receiving peritoneal dialysis. Skilled communication requires health team members to communicate in a respectful, nonintimidating manner with colleagues. True collaboration involves skilled communication, mutual respect, shared responsibility, and decision making among nurses and other health team members. Effective decision making ensures nurses are active, valued partners in making policy, directing and evaluating clinical care, and leading organizational operations. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 506-508

14. A nurse is interested in improving client care on the unit through performance improvement. What is the first step in this process? A. Discover the problem. B. Plan a strategy. C. Implement a change. D. Assess the change.

A Rationale: Each nurse must decide how to respond when one perceives that client care is being compromised. The four steps listed are all components of the process of performance improvement. Discovering the problem is the first step. Planning, implementing, and assessing are steps 2, 3, and 4, respectively, in the performance improvement process. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 507

34. A nurse is evaluating the outcomes identified on the plan of care for first-time parents of a newborn. Which evaluative statement addresses a cognitive outcome? A. 2/6: Outcome met. Parents able to verbalize common problems associated with newborn feeding and appropriate strategies to address them. B. 2/6: Outcome met. Both parents state that they are comfortable and ready to care for their newborn. C. 2/6: Outcome partially met. Mother demonstrated ability to diaper newborn correctly, father still requiring consistent prompting related to steps throughout diaper application. D. 2/6: Both parents reported feeling able to cope with the role changes associated with having a newborn.

A Rationale: The evaluative statement involving the parents' ability to verbalize common newborn feeding problems reflects a cognitive outcome. The evaluative statements involving being comfortable with newborn care and feeling able to cope with role changes address effective outcomes. The evaluative statement involving diapering address a psychomotor outcome. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 502

33. A nurse is a member of a group involved in a quality assurance program. The group is involved in a process evaluation. On which area will the group focus? A. performance of nursing interventions B. hierarchy of the organizational structure C. financial resources D. changes in clients' health status

A Rationale: The focus of a process evaluation is the nature and sequence of activities carried out by nurses implementing the nursing process. A structure evaluation or audit focuses on the environment in which care is provided. Standards describe physical facilities and equipment, organizational characteristics, policies, and procedures, fiscal resources, and personnel resources. Outcome evaluation focuses on measurable changes in the health status of the client, or the end results of nursing care. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 511-512

35. A nurse manager is engaged in a formal evaluation of their own performance as a means of improvement. Which individual is best to provide this feedback to the nurse manager? A. another nurse manager B. director of nursing C. staff nurse on the unit D. nursing shift supervisor

A Rationale: The nurse manager is involved with a peer review—the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This peer review is an important mechanism that nurses can use to improve their professional performance. This can be done formally or informally by inviting a respected peer to give feedback on nursing skills attempting to be developed. The other individuals are not on the same hierarchical level as the nurse manager. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 506-508

17. A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which action should the nurse perform before revising a plan of care? A. Discuss any lack of progress with the client. B. Collect information on abnormal functions. C. Identify the client's health-related problems. D. Select appropriate nursing interventions.

A Rationale: The nurse should discuss any lack of progress with the client so that both the client and the nurse can speculate on what activities need to be discontinued, added, or changed. Collecting information on abnormal functions and risk factors is done during the assessment. Identification of the client's health-related problems is done during diagnosis. Nurses select appropriate nursing interventions and document the plan of care in the planning stage of the nursing process, not during evaluation. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 505

1. Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will: A. terminate the plan of care. B. modify the plan of care. C. continue the plan of care. D. reevaluate the plan of care.

A Rationale: The nurse will terminate the plan of care when each expected outcome has been achieved. Modifying the plan of care is necessary if there are difficulties in achieving the outcomes. Reevaluating each step of the nursing process is a step in the modification of a plan of care. Continuing the plan of care occurs if more time is needed to achieve the outcomes. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 498

30. Which activities does the nurse engage in during the evaluation phase? Select all that apply. A. Collects data to determine whether desired outcomes are met B. Assesses the effectiveness of planned strategies C. Adjusts the time frame to achieve the desired outcomes D. Involves the client and family in formulating desired outcomes E. Initiates activities to achieve the desired outcomes

A, B, C Rationale: During the evaluation stage, the nurse collects data to determine whether desired outcomes are met, assesses the effectiveness of planned strategies, and adjusts the time frame to achieve the desired outcomes. The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage. Question format: Multiple Select Chapter 19: Evaluating Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 498-500

19. Which client outcomes are physiologic outcomes? Select all that apply. A. The client's hemoglobin A1c level is 7.4%. B. The client's blood pressure is 118/74 mm Hg. C. The client rates pain as a 6. D. The client self-administers insulin subcutaneously. E. The client describes manifestations of wound infection.

A, B, C Rationale: Physiologic outcomes are physical changes in the client, such as pain ratings, blood pressure readings, and hemoglobin A1c measurements. Psychomotor outcomes describe the client's achievement of new skills, such as insulin administration. Cognitive outcomes demonstrate gains in client knowledge, such as manifestations of infection. Question format: Multiple Select Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 502

18. Place the following steps for performance improvement in correct sequence. A. Discover a problem. B. Plan a strategy using indicators. C. Implement a change. D. Assess the change.

A, B, C, D Rationale: The correct sequence of steps for performance improvement is (1) discover a problem, (2) plan a strategy using indicators, (3) implement a change, and (4) assess the change. If the change is not met, plan a new strategy. Question format: Drag and Drop Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 507

27. Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse then makes a judgment and documents a statement summarizing those findings. This statement is called: A. a criterion. B. an evaluative statement. C. a standard. D. evidence-based practice.

B Rationale: An evaluative statement is a statement summarizing the client's outcome achievement. Criteria are "measurable qualities, attributes, or characteristics that identify skill, knowledge, or health status." Standards are the "levels of performance accepted by and expected of nursing staff or other health team members." Evidence-based practice incorporates delivering nursing care that evidence supports as likely to result in meeting the expected client outcomes. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 503

4. What is always the primary concern when performing the evaluating step of the nursing process? A. The nurse B. The client C. The health care system D. The efficiency of the nursing process

B Rationale: As members of the health care team, nurses are involved in many types of evaluation. Nurses measure client outcome achievement, how effectively nurses help targeted groups of clients to achieve their specific outcomes, the competence of individual nurses, and the degree to which external factors, such as different types of health care services, specialized equipment or procedures, or socioeconomic factors, influence health and wellness. The client, however, is always the nurse's primary concern, not the nurse, the health care system, or the efficiency of the nursing process. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 498

28. The outcome statement on an infant's plan of care is "The parent will explain proper nutrition for infants." This is an example of which type of outcome statement? A. psychomotor B. cognitive C. affective D. physical changes

B Rationale: Cognitive outcomes are related to achieving greater knowledge. Psychomotor outcomes are those that are related to new skill attainment. Affective outcomes are related to feelings and attitudes. Physical changes are related to actual body changes in the infant. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 501-502

5. What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation? A. Intuitive thinking B. Critical thinking C. Traditional knowing D. Rote memory

B Rationale: Each element of evaluation requires the nurse to use critical thinking about how best to evaluate the client's progress toward valued outcomes. Intuitive thinking is a feeling (a sense) that doesn't use rational processes such as facts and data. Traditional knowledge is a way-of-life wisdom or use of what one knows and applying it to the situation. Rote learning is a memorization technique based on repetition. Nurses do not use intuitive thinking, traditional knowledge, or rote learning to evaluate the client's progress toward valued outcomes. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 498

9. A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would the nurse evaluate this outcome? A. Ask the client to verbally repeat the steps of the injection. B. Ask the client to demonstrate self-injection of insulin. C. Ask family members how much trouble the client is having with injections. D. Ask the client how comfortable the client is with injections.

B Rationale: Psychomotor outcomes describe the client's achievement of new skills and are evaluated by asking the client to demonstrate the new skill. Asking the client to verbally repeat the steps of the injection is a cognitive evaluation. Asking the client how comfortable the client is with injections and asking the family members how much trouble the client is having with injections are affective evaluations. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 502

23. The client demonstrates stair climbing using a quad cane. This is an example of: A. an affective outcome. B. a psychomotor outcome. C. a physiologic outcome. D. a cognitive outcome.

B Rationale: Psychomotor outcomes describe the client's achievement of new skills, such as stair climbing using a quad cane. An affective outcome involves changes in the client's values, beliefs, and attitude. Cognitive outcomes demonstrate increases in client knowledge. Physiologic outcomes are physical changes in the client. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 501-502

25. At the beginning of prenatal care, the goal for the client was to gain 25 lb (11.25 kg) by the end of the pregnancy. At 30 weeks of pregnancy, the client has only gained 1 lb (0.45 kg). Which statement helps the nurse interpret these data appropriately? A. It is too early to evaluate if the goal has been achieved. The client has 10 more weeks of pregnancy. B. The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight. C. The client is progressing toward achieving the goal. The plan should be continued. D. The client has partially achieved the determined goal. The nurse should revise the goal to reflect a more realistic outcome.

B Rationale: The client is not achieving the goal. The nurse should determine what the causes are in order to revise the plan of care. It is important to determine as early as possible if the plan of care is working. This will allow sufficient time to revise the plan of care. It is unrealistic to think the client will achieve the goal in the next 10 weeks. The client may not achieve the goal, but the priority at this time is to determine the reasons and revise the plan of care. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 503

16. A nurse forgets to raise the bed railings of a client who is confused after taking pain medications. The client attempts to get out of bed and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the client only had minor bruises. What would be the appropriate action of the colleague? A. No other steps need to be taken because the client was not seriously injured. B. The colleague should inform the nurse that a full report of the incident needs to be made. C. The colleague should monitor the client closely for any adverse effects of the fall. D. The colleague should report the incident in a peer review of the nurse.

B Rationale: The colleague should tell the nurse that a full report needs to be made. If appropriate, the colleague could help the nurse identify what contributed to the nurse not raising the bed railings in an effort to prevent it from happening in the future. The physician, not the colleague, should monitor the client closely for any adverse effects from the fall. The colleague does not need to report the incident in a peer review of the nurse. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 508

26. A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem? A. Reprimand the nursing personnel responsible for the clients when the falls occurred. B. Investigate the circumstances that contributed to client falls. C. Institute a new policy on the prevention of client falls on the unit. D. Determine if client falls have increased on other units in the hospital.

B Rationale: The most effective method to address the increased frequency of client falls (and to promote a positive working environment) would be to determine the circumstances that contributed to the clients' falls. Attempting to identify and reprimand individual nurses does not lead to an atmosphere of openness and honesty in determining the causes. Instituting a new policy to prevent falls is premature before identifying why the falls are occurring. It may be relevant later to determine if other units are having the same problem, but it is not necessary at this time. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 507

32. While assessing a postoperative client, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000/μL (12 × 109/L), and the client's abdominal wound has a 0.5-in (1.25-cm) gap at the lower end with yellow-green discharge. The nurse would prioritize which intervention? A. Begin intravenous antibiotics. B. Contact the health care provider. C. Apply topical antibiotic ointment. D. Place the client on contact isolation.

B Rationale: Upon assessment of this client, the nurse notes an abnormal white blood cell count and a wound that is not well approximated with purulent discharge. The nurse must prioritize this client's care by contacting the health care provider to determine what adjustments are necessary to the current plan of care. Although the client might need antibiotics, the provider will need to provide additional orders. There is no indication at this time that contact isolation is necessary. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 503-504

13. A nurse has developed a plan of care for a client whose spouse recently died. The nurse assigned the client a nursing diagnosis of: Risk for Loneliness. When the nurse is evaluating the plan, the client tells the nurse new information about having an active social life and being satisfied with social activities. What should the nurse do next? A. Continue with the plan. B. Delete the nursing diagnosis. C. Tell the client that the client is lonely. D. Adjust the time criteria.

B Rationale: When modifying a plan of care, many courses of action are available to the nurse. If a nursing diagnosis is not a problem or concern for the client any longer, the nurse should delete the nursing diagnosis. The nurse should not continue with the plan, because the client's needs have changed. The client's latest report to the nurse indicates that the client is not lonely. There is no need to adjust any time criteria associated with an intervention related to Risk for Loneliness as the client is no longer at risk for loneliness and thus requires no interventions (or associated time criteria) related to this nursing diagnosis. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 506

15. What is evaluated when conducting a nursing audit? A. Physical environment B. Policies and procedures C. Client records D. Client satisfaction

C Rationale: A nursing audit is a method of evaluating nursing care that involves reviewing client records to assess the outcomes of nursing care, or the process by which these outcomes were achieved. A nursing audit does not evaluate the physical environment, policies or procedures, or client satisfaction. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 511-512

6. A nurse is evaluating an established plan of care. After identifying the evaluative criteria and standards (expected patient outcomes), what must the nurse do next? A. Interpret and summarize findings. B. Document the nurse's judgment. C. Collect data about client responses. D. Formulate a new plan of care.

C Rationale: After identifying evaluative criteria and standards (expected patient outcomes), which is the first step in evaluation, the nurse collects data about client responses to determine whether the criteria and standards have been met (step 2). Step 3 is interpreting and summarizing findings. Step 4 is documenting your judgment. Step 5 is terminating, continuing, or modifying the plan. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 512

7. Which descriptor helps to define the term criteria? A. Immeasurable qualities B. Established by authority C. Acceptable level of performance D. Evidence-based practice

C Rationale: Criteria are measurable qualities, attributes, or characteristics that specify skills, knowledge, or health states. They describe acceptable levels of performance by stating the expected behaviors of the nurse or the client. Standards are the levels of performance accepted and expected by the nursing staff or other health team members. They are established by authority, custom, or consent and are based on evidence-based practice. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 501

29. The nurse, orienting a new client to the facility, explains that the staff will ask for and honor the client's preferences and choices while providing care. This represents which expectation of the health care environment? A. Control B. Transparency C. Individualization D. Safety

C Rationale: Individualization is represented by allowing the client to express his or her choices and preferences and then honoring them. The other choices represent other expectations of the health care environment. Transparency is the expectation that the information on all aspects of a client's health and care will be disclosed to the client. Control is the expectation that the client will retain autonomy and the right to self-determination. Safety is the expectation that the client will remain free from harm. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 500

2. An older adult client has lost significant muscle mass during recovery from a systemic infection. As a result, the client has made no progress toward meeting any of the outcomes for mobility and activities of daily living that are specified in the nursing plan of care. How should the nurse best respond to this situation? A. Continue the current plan of care with the hope that the client will achieve the outcomes. B. Terminate the plan of care because it does not now accurately reflect the client's abilities. C. Modify the plan of care to better reflect the client's current functional ability. D. Replace the client's individualized plan of care with a clinical pathway.

C Rationale: Nurses regularly evaluate clients' progression toward the achievement of outcomes that are specified in plans of care. When the achievement of desired outcomes is shown to be unrealistic, it is appropriate to modify the existing plan of care. It is not necessary to wholly terminate the plan of care. Abandoning the plan and replacing it with a clinical pathway is counterproductive to the continuity of care. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 498

10. A plan of care for a client with a low potassium level includes providing information about the effect of medications and about dietary intake of foods high in potassium. How would a nurse measure achievement of an outcome for this plan? A. Physical assessment B. Health history C. Laboratory data D. Client statements

C Rationale: The interventions are aimed at increasing the potassium level of the client, and achievement would be measured by evaluating laboratory data. Potassium levels cannot be measured by physical assessment, health history information, or client statements. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 501-503

20. The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? A. Assessment B. Outcome identification C. Implementation D. Evaluation

D Rationale: Assessing the client's response to a diuretic medication is an example of evaluation. During assessment, the nurse collects and synthesizes data to identify patterns. The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage, such as administration of the diuretic. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 498

8. A nurse is evaluating the outcomes of a plan of care to teach a client with a BMI of 33 about the calorie content of foods. What type of outcome is this? A. psychomotor B. affective C. physiologic D. cognitive

D Rationale: Cognitive goals involve increasing client knowledge. These goals may be evaluated by asking clients to repeat information or to apply new knowledge in their everyday lives. Psychomotor goals focus on movement or performance of a client to perform a skill. Affective goals focus on the client's feelings. Physiologic outcomes are physical changes in the client such as vital signs. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 501

21. The client's expected outcome is "The client will maintain skin integrity by discharge." Which measure is best in evaluating the outcome? A. The client's ability to reposition self in bed B. The presence of a pressure-relieving mattress on the bed C. The percent intake of a diet high in protein D. The condition of the skin over bony prominences

D Rationale: During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse examines client data or behaviors that validate whether the outcome is met. The condition of the skin, especially over bony prominences, provides the best measure of whether skin integrity has been maintained. The client's ability to reposition self in bed, the presence of a pressure-relieving mattress on the bed, and the percent intake of a diet high in protein are all factors that could help maintain skin integrity, but they do not provide a measure of whether or to what degree skin integrity has been maintained. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 501-503

31. The nurse is caring for the client with pneumonia. An expected client outcome is, "The client will maintain adequate oxygenation by discharge." Which outcome criterion indicates the goal is met? A. Client drinks at least 2 to 3 liters of water each day. B. Client completes coughing and deep breathing exercises hourly. C. Client does not demonstrate signs of orthostatic hypotension when ambulating. D. Client no longer requires supplemental oxygen.

D Rationale: The client who is maintaining adequate oxygenation would not require oxygen. Completing required deep breathing exercises is an intervention to achieve the outcome. Drinking adequate amounts of water is not an outcome criteria for achieving adequate oxygenation. Likewise, orthostatic hypotension is not particular to oxygenation outcomes. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 501

12. After a month of pursuing a new nutritional and exercise plan to lose weight, a client has lost 2 lb (0.90 kg) of the 5 lb/month (2.25 kg/month) goal. How should the nurse alter the plan of care in response to this new data? A. The nurse should not alter the plan of care. B. The nurse should change the diet. C. The nurse should delete the nursing diagnosis. D. The nurse should modify the time criteria.

D Rationale: When the nurse has identified the factors contributing to the outcomes not being achieved, the evaluative statement can be used to suggest the necessary revision in the plan of care: (1) delete or modify the nursing diagnosis, (2) make the outcome statement more realistic, (3) increase the complexity of the outcome statement, (4) adjust the time criteria in the outcome statement, or (5) change the nursing intervention. In this case, the diet is working and should not be changed. The client should be given more time to achieve the outcome before changing the plan of care or deleting the diagnosis. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 501-503

22. The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client is breathing easier. The nurse is engaging in which phase of the nursing process? A. Assessing B. Diagnosing C. Planning D. Implementing E. Evaluating

E Rationale: The nurse is collecting evaluative data to determine whether the client is achieving the therapeutic response to the bronchodilator. The implementation was the administration of a bronchodilator. The assessment includes assessing the client's respiratory rate, lung sounds, oxygen saturation, and the previous medical history. Diagnosis would involve identifying the client's problem, which is impaired breathing due to asthma. Planning would involve selecting appropriate interventions, such as administration of a bronchodilator. Question format: Multiple Choice Chapter 19: Evaluating Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 501