Chapter 16: Outcome Identification and Planning
Which nursing diagnosis will the nurse rank as the priority for premature newborn twins?
Altered Gas Exchange
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 computerized information system developed to classify client outcomes is the:
Nursing Outcome Classification system
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?
Outcome
When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
Psychomotor
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?
Seek research about the disorder.
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?
Standardized
A construction worker fractured the right clavicle after a fall on the job and is on the rehabilitation unit working to regain full function of the right arm. Which represents the bestdocumentation of the evaluation of this client?
The client was able to abduct from 0 to 90 degrees with assistance. The client will continue to perform range of motion 3 times per day.
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
discharge planning.
For which client would a standardized plan of care most likely be appropriate?
A client who was admitted for shortness of breath and who has been diagnosed with pneumonia
The nurse is assigned to a client who is newly diagnosed with diabetes. The nurse understands that illness causes feelings of insecurity, which may threaten the client's and family's ability to cope. What action should the nurse take with this client?
Comfort the client and family.
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?
Ongoing
A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?
The client will ambulate with assistance by the nurse to a bedside chair.
According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is:
physiological.
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?
"Please tell me your thoughts about treating this diagnosis."
A client is unconscious and unable to provide input into outcome identification. Which plan of care will the nurse initiate and share with the family?
A plan designed to support the client physically
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 standardized care plan
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 normotensive.
Which intervention performed by the nurse is appropriate for assisting a client in meeting physiological needs based on Maslow's Hierarchy of Needs?
Cutting up food and opening drink containers for the client
Which guideline should the nurse follow when including interventions in a plan of care?
Date the nursing interventions when written and when the plan of care is reviewed.
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?
Developing the plan without client input
A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?
Educational
Which are characteristics of appropriate client outcome statements? Select all that apply.
Measurable Realistic Specific
Which statement correctly describes a nurse-initiated intervention?
Nurse-initiated interventions are derived from the nursing diagnosis.
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?
On the client's admission to the hospital
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?
Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.
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?
Start from client's knowledge, teach about diet modifications, and check for learning.
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?
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?
The client will understand the effects of smoking related to heart disease.
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.
A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:
intervention.
When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:
identifies factors causing undesirable response and preventing desired change.
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?
Add the nursing diagnosis: Risk for Self-Harm.
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?
Encourage hourly use of the incentive spirometer.
Which outcome for a client with a new colostomy is written correctly?
The client will demonstrate proper care of the stoma by 3/29/20.
Which is an appropriate expected outcome for a client?
Client will ambulate safely with walker in the room within 3 days of physical therapy.
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 recognizes that identifying outcomes/goals must include:
involvement of the client and family.
The nurse is discharging a client with chronic obstructive pulmonary disease (COPD). Which statement would the nurse use to teach the client about effective breathing patterns?
"Leaning forward may help you to breathe better."
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?
Narcotic analgesic to treat pain
