Chapter 14: Outcome Identification and Planning

A nurse is reviewing the critical pathway for client and notices that variances have been identified and documented. The nurse understands that the variances are monitored concurrently and retrospectively for continuous quality improvement. Which action would the nurse identify as a function of a variance measurement?

Identifying client problems early in hospitalization.

A nurse working in a critical care unit has formulated the following nursing diagnoses for a client. Which nursing diagnosis mist likely would be of the highest priority?

Impaired gas exchange

The nurse recognizes that identifying outcomes/goals must include:

Involvement of the client and family.

A nursing instructor is explaining the characteristics of different plans of client care to a group of nursing students. Which statement would the instructor include as a major difference about the clinical plan of care as a compared to an instructional plan of care?

Is a practical and concise format with less detail.

The nurse is developing a care plan for a client with a stroke and is including surveillance interventions. What would the nurse most likely include?

Monitoring blood pressure

A nurse is formulating a nursing plan of care for a client based on assessment data. When writing this plan, which would be the most important for the nurse to include?

Nursing interventions

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?

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

A nurse has identified on the plan of care for a client a nursing diagnosis of "Anxiety related to concerns about cancer treatment as evidenced by client's statement." One of the interventions that the nurse writes on the plan of care is to encourage the client to verbalize his feelings about the diagnosis and its effect on his quality of life. The nurse has identified which type of nursing intervention?

Psychoscial

When applying the nurse process, the nurse formulates client outcomes. Which be most important for the nurse to include when writing client outcomes?

Qualifier

What is the primary purpose of the outcome identification and planning steps of the nursing process?

To design a plan of care for and with the client

A nurse is preparing to write client outcomes for a plan of care. Which verb would be least appropriate to use when writing the outcomes?

Understands

The nurse assigned to care for a client has established client outcomes and outcome criteria. After completing this task, what would be the nurse do next?

Write a client plan of care

As part of an assignment, a nursing student is asked to create a concept map for a client. The student asks the instructor, "Why is this necessary? Isn't the plan of care enough?" Which response by the instructor would be most appropriate?

"The map helps you to think more circuital about the relationship between concepts."

A group of nursing students is reviewing information about clinical plans of care. The students demonstrate a need for additional review when they state:

"The plans include a written rationale for each intervention."

A nursing student is developing an outcome criterion for a assigned client. The student demonstrates understanding by including information that answers which questions? Select all that apply.

- Who - What actions - Under what circumstances - How well - When

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using:

Assessment skills

A nurse instructor is describing the Nurse-Sensitive Outcome Classification system to a group of nursing students. The instructor determines that the education has been successful when the students identify which statement as a characteristic feature of Nursing-Sensitive Outcome Classification?

Can be used in a manual or computerized clinical information system.

A nurse is evaluating the outcomes of a plan of care to teach an obese patient about the calorie content of foods. What type of outcome is this?

Cognitive

A client's care plan contains the following information. Which of the following would the nurse identify as the client outcome criteria?

Demonstrates coughing exercises at next session

A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged 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