Chapter 13: Outcome Identification and Planning PrepU
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 normal tensive.
A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?
Client will have formed stools within 24 hours
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
Discharge planning
Jamal is a 16-year-old client admitted to the medical unit 1 hour ago for sickle cell crisis. His vital signs are as follows: T: 36.8°C sublingual, HR: 95, RR: 20, BP: 130/65. He rates his pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. What order is the nurse likely to request first for Jamal?
Narcotic pain medication to treat pain
A nurse is working with a client who is having a difficult time accepting her new diagnosis of type II diabetes. The nurse pulls up a chair next to the client's bed and holds her hand while listening to her story. What type of nursing intervention is the nurse engaging in?
Supportive intervention 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 healthcare.
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 her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?
Upon her admission to the hospital Discharge planning should begin when a client is admitted for treatment.
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 primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration and storage, and conditions that require contact with the health care provider.
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?
Nurses do carry out interventions in response to a physician's order.
A nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The nurse then uses the data to update the client plan of care. What are these actions considered?
Ongoing planning
The nurse recognizes that identifying outcomes/goals must include:
involvement of the client and family.
According to the Nursing Intervention Classification (NIC), the most basic level of nursing intervention is:
Physiologic The most basic domain of the seven domains of Nursing Intervention Classifications is Physiologic: Basic.
Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?
Standardized Standardized care plans are prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem
A 63-year-old client in the ICU 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 her left side she notices that the client has a non-blanching reddened area over her right trochanter. What would be the most appropriate action for the nurse to take?
The nurse repositions the client to her left side and updates the plan of care to turn and reposition the client every hour. Correct
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.
The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?
Mr. Conner will demonstrate proper care of stoma by 3/29/15. Goals must be patient-centered, specific, measurable, attainable, realistic, and timebound. "Mr. Conner will demonstrate proper care of stoma by 3/29/15" has all of these characteristics. "Explain to Mr. Conner the proper care of the stoma by 3/29/15" is a nursing intervention. "Mr. Conner will know how to care for his stoma by 3/29/15" is not measurable. The patient demonstrating a technique is measurable, "will know" is not measurable. "Mr. Conner will be able to care for stoma and cope with psychological loss by 3/29/15" contains two goals in one statement
A nurse is planning nursing interventions for patients on a busy hospital ward. Which guideline would the nurse follow when designing the plan of care?
Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the patient. 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 directly relate to the goal/outcomes, not be a separate entity. The physician does not approve and sign the interventions because they are nursing interventions.
A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?
Ongoing planning Ongoing planning is carried out by any nurse who interacts with the client, 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.
A nurse is caring for a 48-year-old man 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 evaluation An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the outcome criteria.
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.
A nurse is reviewing the outcome criteria that were developed for a client. The nurse determines that the criteria are appropriate because which characteristic is met? Select all that apply. a) are focused short-term b) are specific c) can be measured d) must be broad in scope e) are realistic
• are specific • can be measured • are realistic Outcome criteria are specific, measurable, realistic statements of goal attainment. They may restate the goal, but they also present information that will guide the evaluation phase of the nursing process. To be specific and measurable, certain requirements must be met when writing outcome criteria. Outcome criteria answer the questions who, what actions, under what circumstances, how well, and when. Outcomes may be short- or long-term and are broad statements about what the client's condition will be after nursing intervention.
