Chapter 16 Outcome Identification and Planning

What verbs should the nurse use to write outcomes that are measurable? Select all that apply. • Define • Hear • Know • Feel • Verbalize

Correct response: • Define • Verbalize Explanation: The verb should indicate an observable action that the client is to perform, such as define, prepare, identify, design, list, verbalize, describe, choose, explain, select, apply, and demonstrate. The verbs know, hear, and feel indicate internal states or senses, which are not observable or actions.

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent? • Maintenance • Surveillance • Supervisory • Educational

Correct response: • Educational Explanation: Demonstrating, teaching, and observing a return demonstration are classified as educational interventions. The remaining terms refer to aspects of monitoring the client and do not apply to this scenario.

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

Correct response: • Psychomotor Explanation: Psychomotor interventions include activities such as positioning, inserting, and applying. A psychosocial intervention focuses on supporting, exploring, and encouraging. Maintenance and surveillance are monitoring interventions.

The nurse recognizes that identifying outcomes/goals must include: • involvement of the nurse manager and other staff nurses. • involvement of the client and family. • input from the physician. • input from the multidisciplinary team.

Correct response: • involvement of the client and family. Explanation: One of the most important considerations in writing outcomes is to encourage clients and families to be as involved in goal development as their abilities and interests permit. The more involved they are, the greater the probability that the goals will be achieved. Patient-centered care focuses on the client needs and desires and thus would not require input from the physician, the nurse manager, or multidisciplinary team.

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 • An order set • An algorithm • Guidelines

Correct response: • A standardized care plan Explanation: Standardized care plans are prepared plans of care that identify nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. An algorithm in nursing is a set of developed evidence-based clinical practice guidelines that guides nursing interventions. A guideline is a statement by which to determine a course of action. An order set is a predetermined set of orders by a prescriber that dictates care of the client.

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? • Supportive • Coordinating • Psychosocial • Supervisory

Correct response: • Supportive Explanation: 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 health care.

When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: • identifies client strengths. • identifies factors causing undesirable response and preventing desired change. • identifies the unhealthy response preventing desired change. • suggests client goals to promote desired change.

Correct response: • identifies factors causing undesirable response and preventing desired change. Explanation: The cause of the client health problem is referred to as the etiology. The problem statement of the nursing diagnosis suggests the client goals, and the cause of the problem (etiology) suggests the nursing interventions. Identifying the unhealthy response preventing desired change would occur during the evaluation phase of the nursing process. Client strengths are identified during the nursing diagnosis phase.

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 drowsy after lunch. • Client reports no headache. • Client is normotensive. • Client lipids are within range.

Correct response: • Client is normotensive. Explanation: A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 and 120/80 mm Hg. The other options do not directly indicate successful control of hypertension.

A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "Activity Intolerance." Which expected client outcome most directly demonstrates resolution of the problem? • Client will consistently perform pulmonary exercises. • Client will use oxygen by nasal cannula when short of breath. • Client will increase protein intake in small frequent meals. • Client will alternate rest periods with exercise throughout the day.

Correct response: • Client will alternate rest periods with exercise throughout the day. Explanation: Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will promote health in a client with COPD, the most direct resolution of activity intolerance is for the client to pace activities by alternating rest with exercise throughout the day.

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

Correct response: • Date the nursing interventions when written and when the plan of care is reviewed. Explanation: Nursing interventions describe, and thus communicate to the entire nursing staff and health care team, the specific nursing care to be implemented for the client. 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 be dated both when written and when the care plan is reviewed. The interventions should directly relate to the outcomes. The physician does not approve and sign the interventions, because they are nursing interventions.

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? • Failing to update the written plan of care • Beginning the plan without family to help • Developing the plan without client input • Choosing actions that do not solve the problem

Correct response: • Developing the plan without client input Explanation: Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. There is no indication that the nurse included strategies in the plan of care that did not solve the client's problem. There is no evidence that the care plan needed to be updated or that the nurse failed to do so. Although family support can be important to achieving client outcomes, not every client outcome requires family support.

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

Correct response: • Individualize the plan to the client. Explanation: Standardized plans of care are written by a group of nurses who are experts in a given area of practice (e.g., obstetrics, rehabilitation, orthopedics). The plans are written for a client population with a specific medical diagnosis (e.g., total hip replacement, pressure injury, vaginal delivery, coronary artery bypass surgery). These experts identify the most common nursing diagnoses for this client population and write the goals and interventions usually necessary to resolve the problem. Each time a standardized plan of care is used, it must be individualized for a specific client. The danger of a standardized plan of care lies in the fact that it may not fit a specific client. Nurses must make judgments as to the degree to which standardized plans should be modified or whether they should not be used in individual cases. With a standardized plan of care, the most common nursing diagnoses have already been identified. Rationales are typically not included on clinical plans of care.

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

Correct response: • Nurse-initiated interventions are derived from the nursing diagnosis. Explanation: Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis and do not require a physician's order. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. They are not not performed to diagnose any problem, medical or otherwise, but to help prevent or resolve a problem identified in a nursing diagnosis and thereby to achieve the related expected client outcome.

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

Correct response: • Nurses do carry out interventions in response to a physician's order. Explanation: A physician-initiated intervention is initiated in response to a medical diagnosis, but carried out by a nurse in response to a doctor's order. Both the physician and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding physicians to implement orders, nurses may request a physician to implement an order or question an existing order by the physician if the nurse believes it is in the client's best interests.

A computerized information system developed to classify client outcomes is the: • Nursing Outcome Classification system • Clinical Care Classification System • International Classification of Diseases • NANDA-International list

Correct response: • Nursing Outcome Classification system Explanation: The Nursing Outcome Classification system organizes outcomes according to categories, classes, labels, indicators, and measurement activities. The remaining options do not classify client outcomes. NANDA-International is an organization that develops standardized terminology for nursing diagnosis to ensure client safety and improve client outcomes. The International Classification of Diseases is a classification system for classifying diseases according to diagnosis codes. The Clinical Care Classification System is a standardized system of codes used to label discrete components of nursing practice.

A nurse is caring for a client after a repair of a left femur fracture. The client is immobilized and on strict bed rest, and the nurse provides assistance with position change every 2 hours to prevent pressure injuries. What is the "to prevent pressure injuries" portion of this statement described as? • Nursing diagnosis • Nursing intervention • Outcome • Rationale

Correct response: • Rationale Explanation: The nursing rationale is "why" a nursing intervention is to be performed. In this case, the reason for assisting with position changes is to prevent pressure injuries. The nursing dignosis is the client's health problem that the client outcome and the nursing intervention must address. In this case, the likely nursing diagnosis would be Risk for Impaired Skin Integrity. The client outcome is the goal that the nursing interventions are attempting to achieve. In this case, the client outcome would be something like, "The client will not develop any pressure injuries before discharge." The nursing intervention is an action the nurse takes to address the client's health problem and achieve the client's outcomes. In this case, the nursing intervention is providing assistance with position change every 2 hours.

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? • Follow institutional guidelines. • Consult with another nurse. • Seek research about the disorder. • Set priorities using client care standards.

Correct response: • Seek research about the disorder. Explanation: While each option is appropriate, it is crucial to find research to support the plan before establishing priorities. The nurse planning care uses clinical reasoning to set priorities that incorporate standards and agency policies, identify and record expected client outcomes, select evidence-based nursing interventions, and record the plan of care.

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? • Discharge • Standardized • Ongoing • Initial

Correct response: • Standardized Explanation: 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. Initial, ongoing, and discharge are not types of care plans but of planning, in general. Typically, the nurse develops the client's care plan during initial planning and then updates it as needed during ongoing and discharge planning

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

Correct response: • The client will demonstrate proper care of the stoma by 3/29/20. Explanation: Expected client outcomes must be client-centered, specific, measurable, attainable, realistic, and time-bound. "The client will demonstrate proper care of the stoma by 3/29/20" has all of these characteristics. "Explain to the client the proper care of the stoma by 3/29/20" is a nursing intervention, not an outcome. "The client will know how to care for the stoma by 3/29/20" is not measurable. The client demonstrating a technique is measurable. "The client will be able to care for stoma and cope with psychological loss by 3/29/20" contains two goals in one statement.

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." • "I will take my medications between meals for maximum effect." • "I will mix insulin glargine with insulin lispro at bedtime." • "I will take insulin until my blood sugar levels are normal."

Correct response: • "I will test my glucose level before meals and use sliding scale insulin." Explanation: 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. Diabetes mellitus is a chronic disease, so the client who takes insulin should not expect to ever achieve a normal blood glucose level without taking insulin. The client should test blood glucose level before, not between, meals. Mixing different types of insulin is not necessary.

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

Correct response: • "Please tell me your thoughts about treating this diagnosis." Explanation: In the planning stage of the nursing process, the nurse must focus on the client's interests and preferences, keep an open mind, and include interventions that are supported by research. While the nurse knows that research shows smoking cessation is valuable in successful treatment of lung cancer, the client's choices must be included in the plan for it to be successful. Asking about plans after discharge is too broad and may not elicit the information the nurse needs to design the best plan of care.

Which guidelines should the nurse consider when writing outcomes? Select all that apply. • The nurse should write outcomes that are brief and specific and support the overall plan of care. • The nurse should derive each set of outcomes from a combination of nursing diagnoses. • The nurse may write outcomes that do not specify a timeline as long as they are linked with other outcomes. • The nurse should not be concerned if the client and family do not value the outcomes as long as they support the plan of care. • The outcomes the nurse writes need not be supportive of the total treatment plan as long as they specify a goal. • At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis.

Correct response: • At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. • The nurse should write outcomes that are brief and specific and support the overall plan of care. Explanation: Resolution of the client problem should be a priority; therefore, at least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. Outcomes that are brief and specific are more readily evaluated. The nurse should derive each set of outcomes from a single nursing diagnosis, rather than a combination. The client and family must value the outcomes to work toward the goal. The outcomes must support the overall treatment plan; simply including a goal is not enough. Timelines for outcomes are necessary so that they can be measured and evaluated.

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? • Acetaminophen to treat pain and fever • Septic workup due to blood pressure and heart rate elevation • Isolation for suspected respiratory illness • Narcotic analgesic to treat pain

Correct response: • Narcotic analgesic to treat pain Explanation: A sickle cell crisis is an extremely painful event. Most clients with sickle cell disease have an individualized narcotic plan that will help them to receive narcotics in an expedited manner when they present in crisis. The slight elevations in the client's blood pressure and heart rate are likely secondary to pain, not sepsis. There is no evidence of respiratory illness based on the information given. Acetaminophen is not strong enough to treat this client's pain; furthermore, the client does not have a fever.

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

Correct response: • On the client's admission to the hospital Explanation: Discharge planning should begin when a client is admitted for treatment. All the other times listed are too late and are not consistent with a client who is able to understand the process of the hospitalization.

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? • Initial • Outcome • Discharge • Ongoing

Correct response: • Ongoing Explanation: Ongoing planning is carried out by any nurse who interacts with the client following admission and before discharge, 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. Outcome planning is not a specific type of nursing planning, although it would most likely be performed as part of initial planning.

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? • Cost-effectiveness • Structure • Outcome • Process

Correct response: • Outcome Explanation: An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the expected client outcome. A broad view of evaluation in health care includes three approaches, directed toward structure, process, and outcome, depending on the focus of evaluation and the criteria or standards being used. Process/implementation evaluation determines whether program activities have been implemented as intended. Cost-effectiveness evaluation compares the relative costs to the outcomes (effects) of two or more courses of action. Structure evaluation assesses the effectiveness of various health care structures.

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

Correct response: • Teach the client how to splint an abdominal incision when coughing and deep breathing. Explanation: A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nurse-initiated interventions, such as teaching, do not require a physician's order. A physician's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.

The nurse has identified the following outcome for the client: The client will have a soft, formed stool. Which error has the nurse made in writing the outcome? • The nurse has not made any error in writing the outcome. • The nurse has omitted the time frame. • The outcome should indicate what the nurse will do. • The nurse has omitted the defining characteristics.

Correct response: • The nurse has omitted the time frame. Explanation: Outcomes are client-centered, use action verbs, identify measureable performance criteria, and include a time frame as to when the outcome should be achieved. The time frame has been omitted. Defining characteristics are a component of the nursing diagnosis, not a client outcome. Because outcomes are client-centered, they describe what the client will do, not what the nurse will do.

When creating a care plan, which is the purpose of identifying the client outcome? • To provide a basis for the scientific rationale • To design a plan of care to address the health problem • To coordinate the nursing intervention • To evaluate the plan of care developed

Correct response: • To design a plan of care to address the health problem Explanation: The primary purpose of the outcome identification and planning step of the nursing process is to design a plan of care with and for the client that, once implemented, results in the prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations, as identified in the client outcomes.

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

Correct response: • intervention. Explanation: A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance client goals and outcomes. Nursing diagnoses are statements of the client's actual or potential health problems that the nurse is seeking to address through interventions and are the overarching driver of goal-setting, care planning, and interventions. Evaluation, the final phase of the nursing process, involves assessing the client's response to interventions on an ongoing basis and making any necessary adjustments and changes to the nursing care plan.