Chapter 17: Outcome Identification and Planning PrepU
According to the Nursing Interventions Classification (NIC) system, the most basic level of nursing intervention is: -physiological. -safety. -family. -behavioral.
physiological. Explanation: The NIC is a comprehensive, evidence-based, standardized system for classifying nursing interventions. NIC groups interventions within seven domains, which, in order from the simplest to the most complex, are: Physiological: Basic; Physiological: Complex; Behavioral; Safety; Family; Health System; and Community.
For which client would a standardized plan of care most likely be appropriate? -A client who has been brought to the emergency department with multiple fractures and a suspected head injury after a motor vehicle accident -A client who was admitted for shortness of breath and who has been diagnosed with pneumonia -A client who is receiving treatment for liver cirrhosis, esophageal varices, and hepatic encephalopathy -A client whose increasing fatigue in recent days has not yet been attributed to a specific health problem
A client who was admitted for shortness of breath and who has been diagnosed with pneumonia Explanation: Standardized care plans are most appropriate for clients who are experiencing a common and specific health problem, such as pneumonia. Clients with multiple pathologies or symptoms of unknown etiology are unlikely to have their unique needs reflected in a standardized care plan.
Which nursing diagnosis will the nurse rank as the priority for premature newborn twins? -Altered Gas Exchange -Ineffective Thermoregulation -Interrupted Breastfeeding -Impaired Parenting
Altered Gas Exchange Explanation: Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, circulation, or safety issues such as threats of self-harm. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. Lack of surfactant interferes with lung expansion and can reduce oxygenation in premature infants. Breastfeeding and temperature regulation are of lower importance than oxygenation. Parenting skills may be promoted when parents visit high-risk infants in the nursery.
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 lipids are within range. -Client reports no headache. -Client is normotensive.
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 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? -Choosing actions that do not solve the problem -Failing to update the written plan of care -Beginning the plan without family to help -Developing the plan without client input
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 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 -Initial -Discharge -Outcome
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 reviewing the plan of care for a client and notes: "The client will verbalize three signs of hypoglycemia to the staff accurately before discharge." The nurse should identify this statement as an example which element of nursing practice? -Outcome -Intervention -Nursing diagnosis -Evaluation
Outcome Explanation: This statement is an example of an expected client outcome. Outcomes answer the questions who (the client), what actions (verbalizes), under what circumstances (to the staff), how well (accurately), and when (before discharge). A nursing diagnosis, which identifies a client health problem, would include a diagnostic label, related factors, and defining characteristics. An intervention would reflect an action or treatment the nurse performs to promote client outcomes. An evaluation is not a statement but rather a process of assessing the client's response to nursing interventions.
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. -Consult with another nurse. -Follow institutional guidelines. -Set priorities using client care standards.
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.
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. -Present the client with videos and books about diet changes that reduce inflammation. -Ask the client's learning style, then teach diet information using that style. -Answer the client's questions about diet alterations, and then evaluate understanding.
Start from client's knowledge, teach about diet modifications, and check for learning. Explanation: The nursing interventions written to assist a client to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what assessments need to be made and what nursing interventions, including teaching, counseling, and advocacy, need to be done. They should also include evaluation of the outcome of the intervention. "Start from client's knowledge, teach about diet modifications, and check for learning" provides the most comprehensive intervention for this client, as it includes assessment of the client's current level of knowledge, teaching, and evaluation of the teaching. None of the other answer options includes all three of these elements.
Which is an example of a nurse-initiated intervention? -Administer oxygen at 4 L/min per nasal cannula. -Teach the client how to splint an abdominal incision when coughing and deep breathing. -Administer morphine sulfate 2 mg intravenous push every 3 hours as needed for pain. -Administer a 1000-mL soap suds enema.
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 health care provider's order. A health care provider's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas.
The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing: -discharge planning. -initial planning. -ongoing planning. -comprehensive planning.
discharge planning. Explanation: Discharge planning begins at the time of admission with the nurse teaching the client and family specific 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 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 -Once the client has received a discharge order -As soon as possible after the client's surgery -Once the client is admitted to the nursing unit from postanesthetic recovery
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 nursing student is writing a student care plan for an assigned client. When identifying specific interventions to be used, which aspect would the student need to include with the interventions? -Goals -Scientific rationales -Nursing orders -Outcome criteria
Scientific rationales Explanation: With a student care plan, interventions must be accompanied by the scientific rationales as to the justification or reason for carrying out the interventions. Outcome criteria are specific, measurable, realistic statements that can be evaluated to judge goal attainment. Goals are broad statements that reflect resolution or correction of the identified client problem. Nursing orders is a term that may be used instead of nursing interventions.
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: -medical orders. -condition. -support system. -past medical history.
condition. Explanation: Because a person's condition changes, priorities change. Priorities are based on information collected during reassessment after recovery and assignment to the acute care setting. As the client heals these priorities can shift rapidly. The client's support system would have more of an impact on priorities of care once the client is being discharged to home, not while the client is in the acute care setting immediately after surgery. Both the client's medical orders and the client's nursing priorities change in response to the client's condition, rather than in response to one another. The client's past medical history, which doesn't change, is less likely to affect the nursing priorities of the client after surgery than the client's condition, which does change.
When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "The client will know how to self-administer prescribed bronchodilators using a nebulizer by 09/09/2020." Why is this outcome inadequate? -The outcome is not related to an independent nursing action. -The statement expresses a client outcome as a nursing intervention. -The outcome does not specify the conditions in which it will be achieved. -The outcome is not observable or measurable.
The outcome is not observable or measurable. Explanation: The verb in this outcome, "know," is not directly measurable or observable. The verb "demonstrate" would be more appropriate. Educating a client on how to use a nebulizer is an independent nursing action. The outcome is not expressed as a nursing intervention and conditions are not likely necessary for this outcome.
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 take insulin until my blood sugar levels are normal." -"I will take my medications between meals for maximum effect." -"I will mix insulin glargine with insulin lispro at bedtime." -"I will test my glucose level before meals and use sliding scale insulin."
"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 is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the priority? -By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms -Within 3 days, client will be discharged. -Client will commit to completing a 12-step program within 24 hours of admission. -Client will discuss drinking habits in therapy sessions the day after admission.
By day 2 of admission, the client will remain safe and without injury from withdrawal symptoms Explanation: Safety is a top client priority. About half of all clients with alcohol addiction may develop alcohol withdrawal, which can lead to delirium tremens (DTs) with an estimated 15% fatality rate. The client who can recognize the need for tranquilizers can be treated to avoid DTs. It is unrealistic to expect the client to begin a 12-step program only 48 hours after being admitted in withdrawal. Similarly, starting therapy the day after admission would be premature. There is no way of knowing if a 3-day admission is sufficient for the client's needs.
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 reports no headache. -Client is drowsy after lunch. -Client is normotensive. -Client lipids are within range.
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.
Which is an appropriate expected outcome for a client? -By the next clinic visit, client will report taking antihypertensive medication. -After attending sibling classes, client will be happy about a new infant and demonstrate feeding. -Client will perform complete ostomy care while bathing on the second postoperative day. -Client will ambulate safely with walker in the room within 3 days of physical therapy.
Client will ambulate safely with walker in the room within 3 days of physical therapy. Explanation: Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy meets all of these criteria. "After attending sibling classes, client will be happy about a new infant and demonstrate feeding" is incorrect because it includes more than one client behavior, one of which is not observable or measurable ("be happy"), does not include performance criteria related to how well the client is to demonstrate feeding, and has a vague time frame ("after attending sibling classes"). "By the next clinic visit, client will report taking antihypertensive medication" lacks specificity regarding how often the client should take the medication. "Client will perform complete ostomy care while bathing on the second postoperative day" is likely not attainable within the time frame specified and lacks specificity regarding care the client will provide, making it difficult for the nurse to measure the client's success.
A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem? -Client will eat small meals of bland foods for 3 days. -Client will maintain adequate hydration within 2 days. -Client will identify the food that caused the condition within 3 hours. -Client will have formed stools within 24 hours.
Client will have formed stools within 24 hours. 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 assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal.
A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem? -Client will consistently return to the police station when lost. -Client will not leave the premises without a caregiver. -Client will wear an ID bracelet with name and contact information. -Client will identify landmarks that indicate location of home.
Client will not leave the premises without a caregiver. 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 assist a client with dementia, the most direct resolution of wandering is for the client to remain in the presence of someone who can prevent wandering.
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. -Date the nursing interventions when written and when the plan of care is reviewed. -Make sure the attending health care provider approves of and signs the nursing interventions. -Make sure each nursing intervention does not describe the action the nurse should perform.
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 health care provider does not approve and sign the interventions, because they are nursing interventions.
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. -Promote oral fluid intake between meals. -Provide oral pain medication before ambulation. -Reassess in 4 hours and document the findings.
Encourage hourly use of the incentive spirometer. Explanation: Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions.
A nurse administers colchicine according to the standardized plan of care for a client admitted with acute gouty arthritis of the right great toe. Which assessment information deviates from the expected client outcome for the first 12 hours and requires nursing intervention? -Uric acid level decreases. -Client reports diarrhea. -Foot remains red and swollen. -Client walks to the bathroom.
Foot remains red and swollen. 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 gouty arthritis is reduction in pain. Pain reduction may occur before reduction of redness and swelling is visible. Diarrhea is a possible toxic effect of colchicine.
Which action should the nurse perform during the planning phase of the nursing process? -Assess the client's overall health. -Identify measurable goals or outcomes. -Analyze the client's response to medicines. -Identify the client's health-related problems.
Identify measurable goals or outcomes. Explanation: In the planning phase of the nursing process, the nurse identifies measurable goals or outcomes, prioritizes nursing diagnoses and collaborative problems, selects appropriate interventions, and documents the plan of care. The nurse assesses the client's overall health during the assessment step of the nursing process, not during the planning step. The nurse identifies the client's health-related problems during diagnosis and analyzes the client's response to medicines during the evaluation process.
A nurse is planning care for an adult client with significant cognitive impairments and a new diagnosis of cancer. What nursing action is most appropriate when establishing the priorities of care? -Ask the client what the priority needs are. -Include the client and the client's power of attorney in the discussion. -Consult the oncology nurse specialist in order to determine priorities. -Hold a unit meeting to determine needs.
Include the client and the client's power of attorney in the discussion. Explanation: During the planning step of the nursing process, the nurse develops and prioritizes an individualized plan of care in partnership with the client, family, and others as appropriate. The client with mental or physical limitations should be included in the plan as much as possible. When there are cognitive limits, the client's power of attorney (POA) should also be included in the plans.
Which are characteristics of appropriate client outcome statements? Select all that apply. -Measurable -Realistic -Short-term -Specific -Broad in scope
Measurable Realistic Specific Explanation: Expected client outcomes should be specific (not broad in scope), 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 outcomes. Outcomes answer the questions who, what actions, under what circumstances, how well, and when. Outcomes may be short- or long-term and include a range of expectations about what the client's condition will be after nursing intervention.
Which statement correctly describes a nurse-initiated intervention? -Nurse-initiated interventions are derived from the nursing diagnosis. -Nurse-initiated interventions require a health care provider's order. -Nurse-initiated interventions are actions deemed to have a low risk of harm to the client. -Nurse-initiated interventions are actions performed to diagnose a medical problem.
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 health care provider'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 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 health care provider-initiated intervention (health care provider's order)? -Nurses are responsible for reminding health care providers to implement orders. -Nurses do not carry out health care provider-initiated interventions. -Nurses are not legally responsible for these interventions. -Nurses do carry out interventions in response to a health care provider's order.
Nurses do carry out interventions in response to a health care provider's order. Explanation: A health care provider-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 health care provider and the nurse are legally responsible for these interventions. Although nurses are not responsible for reminding health care providers to implement orders, nurses may request a health care provider to implement an order or question an existing order by the health care provider if the nurse believes it is in the client's best interests.
A computerized information system developed to classify client outcomes is the: -NANDA-International list -Nursing Outcome Classification system -Clinical Care Classification System -International Classification of Diseases
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 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 -Isolation for suspected respiratory illness -Opioid analgesic to treat pain -Septic workup due to blood pressure and heart rate elevation
Opioid analgesic to treat pain Explanation: A sickle cell crisis is an extremely painful event. Most clients with sickle cell disease have an individualized opioid plan that will help them to receive opioids 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 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? -Process -Structure -Outcome -Cost-effectiveness
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.
What are specific measurable and realistic statements of goal attainment? -Outcomes -Evaluations -Nursing diagnoses -Nursing interventions
Outcomes Explanation: Expected client outcomes are specific, measurable, realistic statements of a client's goal attainment. Nursing diagnoses, interventions, and evaluation do not apply to outcomes or goals of nursing care. Nursing diagnoses are statements describing a client's actual or potential health problems that the nurse can treat independently using nursing interventions. Nursing interventions are the actions nurses take to treat the client's health problems. Evaluations are assessments of the effectiveness of interventions in resolving clients' health problems.
A nurse is caring for a client 4 hours following closed reduction and casting of a radial fracture. The client reports pain at 9 on a 1 to 10 scale, and capillary refill is greater than 3 seconds. The cast is bivalved and capillary refill is observed at 2 seconds. What is the best modification to the care plan by the nurse? -Perform hourly neurovascular assessment. -Elevate the injured arm on a pillow. -Apply ice to the casted extremity. -Give prescribed pain meds.
Perform hourly neurovascular assessment. Explanation: Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. This client exhibited a possible complication of impaired peripheral tissue perfusion. The nurse modifies the plan of care to increase the frequency of assessment in order to identify further complication. While the other nursing interventions are routine comfort measures used following injury, they are not sufficient to treat the complication.
A client stops in the hall after walking 30 ft (9 m) and tells the nurse, "I don't want to do any more exercise because I hurt too much." What is the next action the nurse should implement? -Review evidence-based interventions for the client's pain. -Adjust expected outcome to have client ambulate a shorter distance. -Ask the client to describe a personal walking goal. -Return the client to bed and provide pain relief measures.
Return the client to bed and provide pain relief measures. Explanation: While all of these interventions could be used to meet the client's outcomes, the most immediate need is for pain relief. Highest priority nursing diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, or circulation. Safety issues, such as threats of self-harm, are also highest priority. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. This client has a medium level diagnosis because acute pain is interfering with function.
Following knee surgery a client is unable to bend the leg to put on pants, socks, and shoes. The nurse and client set a long-term goal of independence in bathing and dressing. What intervention by the nurse would be most effective in helping the client attain this goal? -Arrange for the social worker to schedule home health care with discharge planning. -Assist the client to put on the clothing that goes over the operated leg. -Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. -Tell the client's family to bring in clothes a size larger to make dressing easier.
Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender. Explanation: Nursing interventions designed to promote client independence will implement methods for the client to perform a skill without help. Assistive devices for eating, bathing, dressing, and ambulation are common tools to develop client independence. The other options do not directly promote independent activity.
The nurse recognizes that an example of a cognitive outcome is: -The client accurately measures the radial pulse for 1 minute by February 2. -The client verbalizes increased confidence in testing glucose levels. -The client demonstrates self-catheterization using clean technique by June 3. -The client identifies three foods high in potassium by August 8.
The client identifies three foods high in potassium by August 8. Explanation: Cognitive outcomes describe increases in client knowledge or intellectual behaviors, such as identifying three foods high in potassium. Demonstrating self-catheterization and measuring the radial pulse are examples of psychomotor outcomes, whereby new skills are achieved. Affective outcomes describe changes in client values, beliefs, and attitudes, such as increased confidence.
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 best documentation of the evaluation of this client? -Passive abduction with assistance -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 client will perform range of motion exercises 3 times per day. -The client performed active range of motion exercises only twice today but states a goal of 3 times per day tomorrow.
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. Explanation: Documentation should be specific. The evaluation is a form of communication with the multidisciplinary health care team that indicates how the client is progressing in meeting expected outcomes. The most detailed documentation of evaluation is the one that provides a numerical measure of the client's range of motion, along with the specific plan for continued evaluation. The remaining options are too general and vague while lacking accountability and stemming from the client perspective.
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 client will ambulate 100 feet without supplementary oxygen or mobility aids. -The client will express an understanding of strategies for managing fatigue and shortness of breath. -The client will demonstrate the correct use of a metered-dose inhaler.
The client will return home able to conduct activities of daily living (ADLs) without experiencing shortness of breath. Explanation: Long-term outcomes require a longer period (usually more than a week) to be achieved than do short-term outcomes. They also may be used as discharge goals, in which case they are more broadly written and communicate to the entire nursing team the desired end results of nursing care for a particular client. Resumption of ADLs in the home setting is characteristic of a long-term outcome. Explaining energy-conservation techniques, mobilizing in the hospital, and demonstrating correct medication administration are short-term outcomes that may be accomplished prior to discharge.
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. -By 8/02, the client will demonstrate a daily meal plan to reduce cholesterol in the diet. -By 8/02, the client will state when to notify the health care provider after discharge -By 08/02, the client will state three therapeutic methods of reducing stress.
The client will understand the effects of smoking related to heart disease. Explanation: Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware." These verbs are too general and cannot be measured. Verbs for writing outcomes should be observable and measurable. The verbs in the distractors are all measurable. The correct response has a goal that the nurse will be unable to measure.
Consider the following statement: "The client will ambulate with the assistance of a cane without incident during a physical therapy session." Which part of the outcome statement does the portion in italics represent? -Verb (action) -Subject -Conditions -Performance criteria
Verb (action) Explanation: The action is one of the essential pieces of an outcome statement. The verb "ambulate" in this case represents the action that the client will perform and that the nurse will monitor and evaluate. The subject refers to the one who performs the action, which is always the client. The conditions are the particular circumstances in or by which the client is to achieve the outcome, such as "with the assistance of a cane" and "during a physical therapy session." The performance criteria are the expected client behaviors or other manifestations described in observable, measurable terms, such as "without incident."
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 know how to care for the stoma by 3/29/20. -The client will demonstrate proper care of the stoma by 3/29/20. -The client will be able to care for stoma and cope with psychological loss by 3/29/20.
he 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.
When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology: -identifies the unhealthy response preventing desired change. -identifies factors causing undesirable response and preventing desired change. -suggests client goals to promote desired change. -identifies client strengths.
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.
The nurse recognizes that identifying outcomes/goals must include: -input from the health care provider. -involvement of the client and family. -involvement of the nurse manager and other staff nurses. -input from the multidisciplinary team.
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. Client-centered care focuses on the client needs and desires and thus would not require input from the health care provider, the nurse manager, or multidisciplinary team.
A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? -"Client will list positive coping strategies and use them." -"Client will identify one coping strategy to try by end of week." -"Client tries using relaxation as a means to cope." -"Client will learn to cope more effectively."
"Client will identify one coping strategy to try by end of week." Explanation: An appropriate outcome includes the client, an action verb, the circumstances by which the outcome is to be achieved, the performance criteria, and time frame. Identifying one coping strategy to try by the end of the week meets these criteria. The statement about the client learning to cope more effectively is not measurable. The statement about listing positive coping strategies and using them includes more than one behavior to evaluate, making it difficult to evaluate achievement. The statement about using relaxation is vague and not really measurable.
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?"
"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.
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 plan made in conjunction with the hospital's ethics committee -A plan derived from a consensus of opinions of all staff members -A plan with problems that are easily solved
A plan designed to support the client physically Explanation: An unconscious client who is unable to provide input into outcome identification depends on the nurse to make informed choices to support the client physically. This care plan would treat any life-threatening situations and act to prevent the development of unhealthy physical consequences. The nurse is in the best position to determine client needs and would not seek the opinion of all staff members or the ethics committee. The care plan would deal with all problems, not just those that are easily solved.
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 -Guidelines -An algorithm
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 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? -Document that the depression has resolved. -Encourage the client to join a therapy group. -Add the nursing diagnosis: Risk for Self-Harm. -Tell another nurse about this client statement.
Add the nursing diagnosis: Risk for Self-Harm. Explanation: Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates risk for self-harm, not resolution of the depression. The nurse will perform additional assessment and add the new nursing diagnosis to the care plan. Changing the care plan to incorporate this new data makes it the most effective for treating the client. Telling another nurse could assist in treatment, but is less formal and less effective, because the entire team needs access to this information. While group therapy may provide help, it does not address the client's current mental health status related to self-harm.
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. -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 health care provider approves of and signs the nursing interventions.
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 health care provider does not approve and sign the interventions, because they are nursing interventions.
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? -Promote oral fluid intake between meals. -Provide oral pain medication before ambulation. -Reassess in 4 hours and document the findings. -Encourage hourly use of the incentive spirometer.
Encourage hourly use of the incentive spirometer. Explanation: Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions.
These nursing diagnoses appear on a client's care plan. Place in the order in which the nurse will prioritize acting upon them. Use all options.
Impaired Swallowing Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image Explanation: Maslow's hierarchy of needs can help nurses prioritize the sequence for addressing client needs. Basic physiologic needs, such as airway, breathing, and circulation, should be resolved before potential needs, or higher level needs such as self-esteem. Impaired swallowing is highest priority because the client may have difficulty ingesting both nutrition and fluids, and also has the potential for aspiration. A current need, such as fluid volume deficit, rates higher priority than a potential problem, risk for impaired skin integrity, or one higher on Maslow's scale, altered body image.
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. -Expect to modify the plan significantly. -Identify the appropriate nursing diagnoses. -Include the rationale for the interventions.
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 actions performed to diagnose a medical problem. -Nurse-initiated interventions require a health care provider's order. -Nurse-initiated interventions are derived from the nursing diagnosis. -Nurse-initiated interventions are actions deemed to have a low risk of harm to the client.
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 health care provider'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 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.
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 will help the client ambulate the length of the hallway once a day. -Offer to help the client walk the length of the hallway each day. -The client will become mobile within a 24-hour period.
Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse. Explanation: 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, is not timebound, and is not client-centered, in that the nurse is the subject of the sentence, not the client. "Offer to help the client walk the length of the hallway each day" is a nursing intervention, not a client outcome. "The client will become mobile within a 24-hour period" is not specific or measurable.
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 intervention -Rationale -Nursing diagnosis -Outcome
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 diagnosis 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.
What behaviors reflect planning? Select all that apply. -The nurse considers the developmental level of the client when selecting education materials. -The nurse assesses the client's usual sleep routine. -The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. -The nurse assists the client with bathing, grooming, and dressing. -The nurse decides to assist the client with ambulation in the hallway twice per shift.
The nurse decides to assist the client with ambulation in the hallway twice per shift. The nurse seeks input from the client and family regarding acceptable, nonpharmacologic pain management strategies. The nurse considers the developmental level of the client when selecting education materials. Explanation: Planning involves selecting evidence-based nursing interventions that will best address a client's problems as specified in the nursing diagnoses and thereby achieve the client's planned outcomes. Deciding to assist the client with ambulation, seeking input from the client and family on pain management, and considering a client's developmental level when selecting educational materials are all actions involving the nurse selecting interventions to best meet the client's needs. Assessing the client's usual sleep routine is an example of the assessment phase of the nursing process, not the planning phase. Assisting the client with bathing, grooming, and dressing is an example of the implementation phase of the nursing process, not the planning phase.
A client is required to have nothing by mouth (NPO) for 8 hours prior to a test scheduled for tomorrow. What action by the nurse best communicates this change in basic care needs for the client? -Updating the diet orders in the client's plan of care -Adding the diagnosis "Altered Nutrition, Less Than Required" -Posting the sign "NPO after midnight" over the bed -Obtaining written consent for the diagnostic procedure
Updating the diet orders in the client's plan of care Explanation: The plan of care communicates three different types of nursing care: care related to meeting basic human needs, care related to nursing diagnoses, and care that must be coordinated with medical and interdisciplinary providers. Nutrition is a basic human need. The temporary need to withhold food and fluid should be documented in the record. The other options are not the best, most direct methods for conveying this information to all who may need it.
