class 7 - chapter 17: outcome identification and planning

A nurse is reviewing the plan of care for a client. Which statement would the nurse identify as an appropriate outcome? "Client will learn to cope more effectively." "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 identify one coping strategy to try by end of week."

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.

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.

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.

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.

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

Nurses do carry out interventions in response to a health care provider's order.

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

Nursing Outcome Classification system

Which is most important for the nurse to include in a client's plan of care? Nursing interventions Evaluation Assessment data Medical diagnoses

Nursing interventions

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

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

When planning a client's care, the nurse has drafted specific, measurable and realistic statements of goal attainment. What component of the care planning process has the nurse included? Nursing diagnoses Nursing interventions Evaluations Outcomes

Outcomes

When a nurse documents an intervention involving a one-person assist of a client to the chair, which type of nursing intervention does this represent? Maintenance Surveillance Psychomotor Psychosocial

Psychomotor

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 08/02, the client will state three therapeutic methods of reducing stress. 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

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: support system. medical orders. past medical history. condition.

condition.

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.

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.

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

involvement of the client and family.

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."

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 derived from a consensus of opinions of all staff members A plan with problems that are easily solved A plan made in conjunction with the hospital's ethics committee

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 An order set Guidelines An algorithm

A standardized care plan

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. Tell another nurse about this client statement. Encourage the client to join a therapy group. Document that the depression has resolved.

Add the nursing diagnosis: Risk for Self-Harm.

Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer? By the next clinic visit, the client will report needing antiemetic medication. After attending a cancer support group, the client will report being in a good mood. By discharge, the client will perform hand hygiene before and after port care. The client will schedule radiation therapy sessions and plan for chemotherapy.

By discharge, the client will perform hand hygiene before and after port care.

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.

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 ambulate safely with walker in the room within 3 days of physical therapy. 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.

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 Seeking input from the client regarding preferences for a snack Providing the mother the phone number for the Poison Control Center Assisting the client to validate feelings regarding treatment options

Cutting up food and opening drink containers for the client

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.

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

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.

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

Teach the client how to splint an abdominal incision when coughing and deep breathing.

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? The client will perform range of motion exercises 3 times per day. 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 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.

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)

The nurse is selecting interventions after gathering and analyzing client data. Interventions that the nurse includes will meet what criterion? Time-specific Multidisciplinary Aligned with a goal Based on collaboration with the care provider

Aligned with a goal

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. Client will eat small meals of bland foods for 3 days. Client will identify the food that caused the condition within 3 hours. Client will maintain adequate hydration within 2 days.

Client will have formed stools within 24 hours.

After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care? It helps deliver holistic, goal-oriented, individualized care. It creates a teaching log for family. It verifies staffing. It provides the client with information about treatments.

It helps deliver holistic, goal-oriented, individualized care.

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? Rationale Outcome Nursing intervention Nursing diagnosis

Rationale

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.

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 Psychosocial Coordinating Supervisory

Supportive

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.

The client will demonstrate proper care of the stoma by 3/29/20.

What behaviors reflect planning? Select all that apply. 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. The nurse assesses the client's usual sleep routine. 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 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.

Which actions occur during the initial planning of client care? Select all that apply. The nurse who performs the admission nursing history and physical assessment makes the initial plan. After the initial plan is developed, the nurse prioritizes nursing diagnoses. The nurse identifies client goals and the related nursing care in the initial plan. The nurse uses tailored plans as opposed to standardized care plans as a basis for the initial plan. The nurse collects new data and analyzes them to make the plan more specific and effective. The nurse making the initial plan focuses on using education and counseling skills to help the client carry out necessary self-care behaviors at home.

The nurse who performs the admission nursing history and physical assessment makes the initial plan. After the initial plan is developed, the nurse prioritizes nursing diagnoses. The nurse identifies client goals and the related nursing care in the initial plan.

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? Posting the sign "NPO after midnight" over the bed Updating the diet orders in the client's plan of care Obtaining written consent for the diagnostic procedure Adding the diagnosis "Altered Nutrition, Less Than Required"

Updating the diet orders in the client's plan of care