Ch 16: Outcome Identification and Planning

A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? A) Client will have formed stools within 24 hours. B) Client will eat small meals of bland foods for 3 days. C) Client will identify the food that caused the condition within 3 hours. D) Client will maintain adequate hydration within 2 days.

A) Client will have formed stools within 24 hours.

According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is: A) behavioral. B) safety. C) physiological. D) family.

C) physiological.

A nurse writes down the following outcome for a depressed client: "By 6/9/20, the client will state three positive benefits of receiving counseling." This is an example of which type of outcome? A) Psychomotor B) Cognitive C) Affective D) Realistic

C) Affective

Although each care plan is individualized, clients undergoing similar medical or surgical treatments often have certain risks and health problems in common and therefore can benefit from a common care plan. What name is given to this type of care plan? A) Initial B) Ongoing C) Discharge D) Standardized

D) Standardized

Which action should the nurse perform during the planning phase of the nursing process? A) Assess the client's overall health. B) Identify measurable goals or outcomes. C) Analyze the client's response to medicines. D) Identify the client's health-related problems.

B) Identify measurable goals or outcomes.

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 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? A) "I will take insulin until my blood sugar levels are normal." B) "I will take my medications between meals for maximum effect." C) "I will mix insulin glargine with insulin lispro at bedtime." D) "I will test my glucose level before meals and use sliding scale insulin."

D) "I will test my glucose level before meals and use sliding scale insulin."

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) Add the nursing diagnosis: Risk for Self-Harm. B) Tell another nurse about this client statement. C) Encourage the client to join a therapy group. D) Document that the depression has resolved.

A) Add the nursing diagnosis: Risk for Self-Harm.

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? A) Ongoing B) Initial C) Discharge D) Outcome

A) Ongoing

Which are characteristics of appropriate client outcome statements? Select all that apply. A) Realistic B) Specific C) Short-term D) Broad in scope E) Measurable

A) Realistic B) Specific E) Measurable

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

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) An order set B) Guidelines C) A standardized care plan D) An algorithm

C) A standardized care plan

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? A) Maintenance B) Surveillance C) Psychomotor D) Psychosocial

C) Psychomotor

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing: A) diagnosis. B) evaluation. C) intervention. D) goal.

C) intervention.

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) Process B) Structure C) Outcome D) Cost-effectiveness

C) Outcome

Which statement correctly describes a nurse-initiated intervention? A) Nurse-initiated interventions are derived from the nursing diagnosis. B) Nurse-initiated interventions require a physician's order. C) Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. D) Nurse-initiated interventions are actions performed to diagnose a medical problem.

A) Nurse-initiated interventions are derived from the nursing diagnosis.

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: A) discharge planning. B) initial planning. C) ongoing planning. D) comprehensive planning.

A) discharge planning.

The nurse recognizes that an example of a cognitive outcome is: A) The client demonstrates self-catheterization using clean technique by June 3. B) The client identifies three foods high in potassium by August 8. C) The client accurately measures the radial pulse for 1 minute by February 2. D) The client verbalizes increased confidence in testing glucose levels.

B) The client identifies three foods high in potassium by August 8.

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

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 A) does not contain documented scientific rationales. B) does not contain abbreviated nursing diagnoses. C) separates goal statements from the plan of care. D) separates outcome criteria from the plan of care.

A) does not contain documented scientific rationales.

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) Choosing actions that do not solve the problem B) Failing to update the written plan of care C) Beginning the plan without family to help D) Developing the plan without client input

D) Developing the plan without client input

Which action should the nurse perform during the planning step of the nursing process? A) Interprets and analyzes the client data B) Establishes a database for the client C) Identifies client strengths and weaknesses D) Selects nursing measures, including client education

D) Selects nursing measures, including client education

Which is an example of a nurse-initiated intervention? A) Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. B) Administer oxygen at 4 L/min per nasal cannula. C) Administer a 1000-mL soap suds enema. D) Teach the client how to splint an abdominal incision when coughing and deep breathing.

D) Teach the client how to splint an abdominal incision when coughing and deep breathing.

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 selected based on the etiology in the nursing diagnosis and must be compatible with other therapies planned for the client." B) "The client's developmental level, values, beliefs, and cultural and psychosocial background should be considered when selecting nursing interventions." C) "Nursing interventions should be consistent with standards of nursing care and research findings." D) "Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

D) "Nursing interventions are pretty much the same for clients that have the same medical diagnosis."

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 D0 Clinical Care Classification System

B) Nursing Outcome Classification system

A nurse is using a standardized plan of care for a client. Which action would be most important for the nurse to do? A) Individualize the plan to the client. B) Expect to modify the plan significantly. C) Identify the appropriate nursing diagnoses. D) Include the rationale for the interventions.

A) Individualize the plan to the client.

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? A) "Client will learn to cope more effectively." B) "Client will list positive coping strategies and use them." C) "Client will identify one coping strategy to try by end of week." D) "Client tries using relaxation as a means to cope."

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

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 is normotensive. D) Client lipids are within range.

C) Client is normotensive.

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) support system. B) medical orders. C) past medical history. D) condition.

D) condition.

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) Encourage hourly use of the incentive spirometer. B) Promote oral fluid intake between meals. C) Provide oral pain medication before ambulation. D) Reassess in 4 hours and document the findings.

A) Encourage hourly use of the incentive spirometer.

Which is the primary benefit of outcome identification? A) It allows the nurse to evaluate the outcomes. B) It promotes the client being an active participant in care. C) It promotes an effective diagnostic process. D) It allows for the identification of proper diagnoses.

B) It promotes the client being an active participant in care.

Which outcome for a client with a new colostomy is written correctly? A) Explain to the client the proper care of the stoma by 3/29/20. B) The client will know how to care for the stoma by 3/29/20. C) The client will demonstrate proper care of the stoma by 3/29/20. D) The client will be able to care for stoma and cope with psychological loss by 3/29/20.

C) The client will demonstrate proper care of the stoma by 3/29/20.

The nurse has identified short- and long-term goals for a client after surgery to remove a leg tumor. When determining interventions for the goals, which questions are important for the nurse to consider? Select all that apply. A) Are the interventions compatible with other planned therapies? B) Are the interventions evidence-based? C) Are the interventions realistic and do they require resources available to the nurse? D) Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background? E) Are the interventions valued by the nursing staff?

A) Are the interventions compatible with other planned therapies? B) Are the interventions evidence-based? C) Are the interventions realistic and do they require resources available to the nurse? D) Are the interventions compatible with the client's values, beliefs, and cultural and psychosocial background?

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) Narcotic 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) Narcotic analgesic to treat pain

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) Start from client's knowledge, teach about diet modifications, and check for learning. B) Present the client with videos and books about diet changes that reduce inflammation. 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.

A) Start from client's knowledge, teach about diet modifications, and check for learning.

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.

Which is an example of a psychomotor outcome? A) Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change. B) Within 1 week of attending class, the client will have cut smoking from 20 to 10 cigarettes per day. C) The client will verbalize understanding of the need to continue to take medications as prescribed. D) The client's skin will remain smooth, moist, and without breakdown or ulceration.

A) Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

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) "You need to stop smoking for us to effectively combat this disease." B) "Please tell me your thoughts about treating this diagnosis." C) "Do you want to be discharged without treatment?" D) "What are your plans after discharge?"

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

A nurse identifies the following nursing diagnosis for a client with an infected leg ulcer: "Deficient Knowledge related to diminished peripheral circulation and wound care as evidenced by recurrent infected leg ulcer." Which statement would the nurse identify as addressing a cognitive outcome? A) "The client demonstrates how to irrigate leg wound." B) "The client states the reason for wound care measures." C) "Client chooses correct size of dressing to cover the wound." D) "Client verbalizes being motivated to continue follow-up to prevent recurrence."

B) "The client states the reason for wound care measures."

Which guideline should the nurse follow when including interventions in a plan of care? A) Make sure the nursing interventions are unrelated to the original outcomes. B) Date the nursing interventions when written and when the plan of care is reviewed. C) Make sure the attending physician approves of and signs the nursing interventions. D) Make sure each nursing intervention does not describe the action the nurse should perform.

B) Date the nursing interventions when written and when the plan of care is reviewed.

What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? A) Nurses do not carry out physician-initiated interventions. B) Nurses do carry out interventions in response to a physician's order. C) Nurses are responsible for reminding physicians to implement orders. D) Nurses are not legally responsible for these interventions.

B) Nurses do carry out interventions in response to a physician's order.

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? A) The nurse will help the client ambulate the length of the hallway once a day. B) Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. C) Offer to help the client walk the length of the hallway each day. D) The client will become mobile within a 24-hour period.

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

A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse? A) Elevate the injured arm on a pillow. B) Perform hourly neurovascular assessment. C) Apply ice to the casted extremity. D) Give prescribed pain meds.

B) Perform hourly neurovascular assessment.

A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement? A) Adjust expected outcome to have client ambulate a shorter distance. B) Return the client to bed and provide pain relief measures. C) Ask the client to describe a personal walking goal. D) Review evidence-based interventions for the client's pain.

B) Return the client to bed and provide pain relief measures.

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) Seek research about the disorder. C) Follow institutional guidelines. D) Set priorities using client care standards.

B) Seek research about the disorder.

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 baby 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.

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) Once the client has received a discharge order B) As soon as possible after the client's surgery C) On the client's admission to the hospital D) Once the client is admitted to the nursing unit from postanesthetic recovery

C) On the client's admission to the hospital

A client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which statement constitutes a long-term outcome for this client? A) The client will express an understanding of strategies for managing fatigue and shortness of breath. B) The client will ambulate 100 feet without supplementary oxygen or mobility aids. C) The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. D) The client will demonstrate the correct use of a metered-dose inhaler.

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

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 demonstrate a daily meal plan to reduce cholesterol in the diet. C) The client will understand the effects of smoking related to heart disease. D) By 8/02, the client will state when to notify the health care provider after discharge

C) The client will understand the effects of smoking related to heart disease.