Chapter 13: Outcome Identification and Planning

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: a) Discharge planning b) Ongoing planning c) Initial planning d) Comprehensive planning

a Discharge planning begins at the time of admission with the nurse teaching the client and family specific knowledge and 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.

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem? a) Client will consistently return to the police station when lost. b) Client will not leave the premises without a caregiver. c) Client will wear an ID bracelet with name and contact information. d) Client will identify landmarks that indicate location of home.

b

The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention? a) Administer oxygen 4 L/min per nasal cannula. b) Administer morphine sulfate 2 mg IV push every 3 hours as needed for pain. c) Teach client how to splint abdominal incision when coughing and deep breathing. d) Administer a 1000 ml soap suds enema.

c

Which is an appropriate expected outcome for a client? a) Client will perform complete ostomy care while bathing on the second postoperative day. 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) By the next clinic visit, client will report taking antihypertensive medication.

c Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy is a specific and reasonably attainable goal. Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable such as "know" and "understand".

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? a) Cost-effectiveness evaluation b) Process evaluation c) Structure evaluation d) Outcome evaluation

d An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the outcome criteria.

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? a) Psychosocial intervention b) Supportive intervention c) Supervisory intervention d) Coordinating intervention

b

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) medical orders. b) condition. c) past medical history. d) support system.

b

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent? a) Psychosocial b) Surveillance c) Maintenance d) Psychomotor

d

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? a) Make sure the nursing interventions are approved of and signed by the attending physician. b) Date the nursing interventions when written and when the plan of care is reviewed. c) Make sure the nursing interventions are a separate entity from the original goal/ outcomes. d) Make sure the nursing intervention does not describe the nursing action to be performed.

b

A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this client? a) The client will become mobile within a 24-hour period. b) Offer to help the client walk the length of the hallway each day. c) Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. d) The nurse will help the client ambulate the length of the hallway once a day.

c 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 and it is not timebound. "Offer to help the client walk the length of the hallway each day" is a nursing intervention. "The client will become mobile within a 24-hour period" is not specific or measurable