evaluation ch 15 coursepoint

Which action should the nurse take during the evaluation phase of the nursing process?

Document reassessment of pain after medication administration. The evaluation phase includes documenting a reassessment of pain following an intervention such as the administration of pain medication. Providing a client with an appointment and discontinuing an indwelling urinary catheter are interventions. Having a client give input into a plan of care is part of the planning process.

When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate?

"Demonstrated steps" Written documentation of the subjective and objective data gathered and the judgment made about goal attainment is required on the client's health record. Judgments about goal attainment are written clearly and concisely. Avoid ambiguous terminology, such as "inadequate," "good," or "extremely well," which can be interpreted differently by different people.

A client has been diagnosed with pneumonia and is experiencing chest pain when taking a deep breath. What are the two priority nursing diagnoses?

Acute Pain Ineffective Airway Clearance While all are important diagnoses, respiratory function and pain are priority.

Which action is appropriate when evaluating a client's responses to a plan of care?

Continue the plan of care if more time is needed to achieve the goals/outcomes. The client's goals/outcomes sometimes are not met or partially met only because more time is needed for the plan of care to be effective. It is not necessary to reinforce the plan of care when each expected outcome is achieved because as goals are met, the plan can simply continue to the next goal. Termination of the plan is not warranted due to difficulties in achieving goals/outcomes; modifications to the plan of care may only be required. The plan of care may continue past discharge if necessary.

For a client with self-care deficit, the long-term goal is that the client will be able to dress himself by the end of the 6-week therapy. For best results, when should the nurse evaluate the client's progress toward this goal?

as soon as possible Evaluating the progress of a long-term goal prior to the end date will encourage and motivate the client to continue working towards the goal. Waiting until the client is discharged or at the end of the 6 weeks does not provide the client the opportunity to feel a sense of accomplishment and motivation to continue working towards the goal. Only evaluating when the client shows progress may lead to the client becoming discouraged.

Identifying the kind and amount of nursing services required is a possible solution for:

inadequate staffing. A possible solution for inadequate staffing is to identify the kind and amount of nursing services required. Using a team conference to develop a consistent plan of care is a possible solution for the client who refused to cooperate with the therapeutic regimen. Educating the client to become an assertive health care consumer is a possible solution for the client who quietly accepts whatever care is delivered or not delivered. A possible solution for the nurse who is a candidate for burnout is to learn to give quality care during the designated work period.

Which nursing action reflects evaluation?

The nurse assesses urine output following administration of a diuretic. Assessing the client's response to a diuretic medication is an example of evaluation. Recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as activity intolerance, is the focus of diagnosing. Auscultating the client's lungs and abdomen is an example of assessment. Setting a tolerable pain rating with the client is an example of planning.

A nurse incorrectly administers digoxin to her client. The nurse admits her actions to the nurse manager and to her peers in an effort to prevent them from making the same mistake. This is an example of:

quality by opportunity. In this example, the nurse is attempting to improve quality through the opportunity of sharing her experience to help other nurses.

A nurse caring for an older adult client who has dementia observes another nurse putting restraints on the client without a physician's order. The client is agitated and not cooperating. What would be the best initial action of the first nurse in this situation?

Confront the nurse and explain how this could be dangerous for the client. Confronting the nurse and explaining the danger for the client is a form of peer evaluation. Peer evaluation involves evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This is an important mechanism nurses can use to improve their professional performance; it can be done formally or informally. Reporting the nurse does not enhance a good working relationship and does not follow the chain of command. An incident report is not warranted at this point in time. The physician should not be contacted for an order unless it is decided that the restraint is going to be left on the client.

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of:

a cognitive outcome. Cognitive outcomes demonstrate increases in client knowledge, such as strategies for minimizing leakage of an ileostomy bag. An affective outcome involves changes in the client's values, beliefs, and attitude. Physiologic outcomes are physical changes in the client. Psychomotor outcomes describe the client's achievement of new skills.

The client demonstrates stair climbing using a quad cane. This is an example of:

a psychomotor outcome. Psychomotor outcomes describe the client's achievement of new skills, such as stair climbing using a quad cane. An affective outcome involves changes in the client's values, beliefs, and attitude. Cognitive outcomes demonstrate increases in client knowledge. Physiologic outcomes are physical changes in the client.

A client with a recently fractured left femur has been reluctant to comply with his physical therapy for fear of the pain associated with movement. A goal for this client is to attend therapy treatments 3 times each day. The nurse is evaluating the goal for this client. The client states, "I don't like therapy; it hurts, but I have been going twice a day." The client chart has an entry from the last shift nurse stating the client went to therapy 2 times with encouragement. The nurse evaluates the goal as:

goal partially met. After collecting data, nurses form a comprehensive picture of the client's behavioral responses. The next activity is to make a judgment about goal attainment by comparing the client's actual behavioral responses to the predicted responses or predetermined outcome criteria developed in the planning phase.

The nurse manager observes one of the unit nurses failing to was her hands upon entering a client room. Hospital protocol is washing hands before and after entering a client room. The nurse manager knows that this is an example of:

quality by inspection. Quality by inspection is met by nurses watching for deficient workers and removing them in an effort to prevent harm to clients.

The terms "criteria" and "standard" are often used interchangeably but actually have distinct, separate definitions. "The levels of performance accepted by, and expected of, nursing staff or other health team members" is known as:

standards. Standards are the "levels of performance accepted by and expected of nursing staff or other health team members." Criteria are "measurable qualities, attributes, or characteristics that identify skill, knowledge, or health status." Evidence-based practice incorporates delivering nursing care that evidence supports as likely to result in meeting the expected client outcomes. Evaluation involves measuring how well the client has achieved the outcomes that were set forth in the plan of care.

The nursing supervisor is evaluating how many clients each of the department nurses has been assigned for the shift. This type of evaluation would be considered:

structure. Availability of equipment, layout of physical facilities, nurse-client ratios, administrative support, and maintenance of nursing staff competence are some areas of concern for structure evaluation.

Which nursing action reflects evaluation?

The nurse assesses the client's response to pain medication Examples of evaluation include assessing the client's response to pain medication. The focus of diagnosing is recognition of a client health problem that can be prevented or resolved by independent nursing intervention, such as a wound infection. Setting an anxiety rating with the client is an example of is an example of planning. Performing colostomy irrigation is an example of implementation.

The nurse participates in a quality assurance program and reviewing evaluation data from the previous year. Which of the following does the nurse recognize as an example of outcome evaluation?

A 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. Structure evaluation focuses on the environment in which care is provided, such as the number of baccalaureate-prepared nurses employed in the facility and bed occupancy rates. Process evaluation focuses on the nature and sequence of activities carried out by nursing implementing the nursing process, such as 98% of all hospital admissions had a nursing history completed within 24 hours of admission.

Once a nurse has collected and interpreted the data on a client's outcome achievement, the nurse will then make a judgment and document a statement summarizing those findings. This is called:

Evaluative statement An evaluative statement is a statement summarizing the client's outcome achievement. Criteria are "measurable qualities, attributes, or characteristics that identify skill, knowledge, or health status." Standards are the "levels of performance accepted by and expected of nursing staff or other health team members." Evidence-based practice incorporates delivering nursing care that evidence supports as likely to result in meeting the expected client outcomes.

Nurses formulate different types of goals for clients when planning client care. What is considered a psychomotor client goal?

By 18AUG2015, client will demonstrate improved motion in left arm. Psychomotor client goals refer to the client's achievement of new skills, such as demonstrating improved motion in the left arm. Valuing health by quitting smoking is an example of a quality of life goal/outcome. Listing three foods low in salt is a cognitive goal/outcome. Learning exercises to strengthen leg muscles is an affective goal/outcome.

Nurses are involved in many types of evaluation. All of the activities listed are related to evaluation, but which activity is the priority concern for nurses?

Clients and their care The priority concern for nurses should always be related to care of clients. The other choices are all activities related to evaluation but are not the priority.

A client comes into the clinic for a routine postoperative visit. While the nurse is assessing the level of pain, the client states that there is occasional discomfort but that pain levels have improved daily since returning home from the hospital. What should the nurse's response be regarding the client's plan of care?

Continue the plan of care. The nurse should continue the plan of care, as the client is progressing toward the ultimate outcome—the healing of the surgical site. There is no need to modify the plan, as the client is responding. The client is still having some pain so it would not be appropriate to discontinue the plan of care. With the improvement in the client's pain, there is no need to increase pain medication; the nurse should just remind the client to take it when pain is uncomfortable.

A hospital is revising its quality improvement program. The goal of the program is to improve quality in the facility. Which of the following are major premises of the program? (Select all that apply)

Customer orientation Leadership commitment Empowerment Focus on the organizational mission Focus is not on unit nurses in a quality improvement program. It is focused on client care and the other choices noted above.

The nurse manager is holding a staff meeting and indicates that the unit is looking at a 3% budget cut for the coming year. The nurse manager asks the staff what they see as priorities for the unit, and solicits suggestions from the staff as to what budget areas might be reduced. Which standard for establishing and sustaining healthy work environments does this action represent?

Effective decision making Effective decision making ensures nurses are active, valued partners in making policy, directing and evaluating clinical care, and leading organizational operations. Appropriate staffing ensures that client needs are effectively matched with nurse competencies. Micromanagement would be demonstrated by the manager not asking for opinions and proceeding with decision making without input. Meaningful recognition highlights the value each nurse brings to the work for the organization, such as certification.

The nurse is caring for Mr. M., a 48-year-old man with congestive heart failure. The nurse manager informs the nurse that Mr. M. was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Outcome evaluation An outcome evaluation determines the extent to which a client's behavioral response to a nursing intervention reflects the outcome criteria.

A group of nurses of the orthopedic floor of a hospital wish to improve their clinical performance. The nurse manager suggests a program in which the nurses will evaluate each other and provide feedback for improved performance. The nurses know that this program is termed:

Peer review Peer review is a process by which one nurse evaluates the performance of another in an effort to improve professional performance. QSEN has as its goal the preparation of nurses with the knowledge, skills, and attitudes (KSAs) necessary to improve the quality and safety of health care systems. AACN strives to provide safe work environments. HCAHPS measures client satisfaction with health care.

A nurse is reviewing the plan of care for a client. What might the nurse identify are problems related to the planning phase of the nursing process? Select all that apply.

Plan of care only contains standard knowledge that most nurses would implement if there was a plan of care. Long-term goal is vague. Outcomes are incorrectly developed. Nursing orders are superficial. Database input is done during the assessment phase of the plan of care. The other choices are all completed during the planning phase of the nursing process.

A nurse is evaluating the outcome of the plan of care after teaching a client how to prepare and administer an insulin pen. Which type of outcome is the nurse addressing?

Psychomotor Preparing and administering an insulin pen is a psychomotor outcome. Psychomotor outcomes describes the client's achievement of new skills. Cognitive outcomes describe increase in client knowledge or intellectual behaviors. Affective outcomes describe changes in client values, beliefs, and attitudes. Physiologic outcomes are concerned with how the human body works.

The Joint Commission is conducting an accreditation visit at the hospital. What is the focus of the evaluation being conducted?

Quality assurance Accreditation by the Joint Commission evaluates quality assurance. Quality assurance is an externally driven process, demonstrating nursing excellence by meeting professional standards of care. Quality improvement is an internally driven, continuous process focusing on the processes of client care. Peer review is a process whereby individual nurses improve their professional performance through the evaluation of one staff member by another staff member on the same level of the hierarchy. Magnet status is awarded by the American Nurses Credentialing Center, recognizing health care organizations for their excellence in nursing.

Which action should the nurse take when client data indicate that the stated goals have not been achieved?

Review each preceding step of the nursing process. If a client's goal has not been achieved the nurse should review each of the preceding steps of the nursing process in order to try to identify the contributing factors causing problems with the plan of care. By conducting the evaluation this way, the nurse may find that more data must be collected or the plan of care needs revision. An individualized plan of care rather than a standardized plan of care is often warranted.

A nurse is caring for a client who is recovering from stroke. Which action would the nurse perform in the evaluation phase?

Revise the plan of care. The nurse should revise the plan of care during the evaluation phase. It provides the feedback mechanism that starts the entire chain of events again. Setting priorities is part of the planning phase. Carrying out treatment procedures and recording interventions are activities in the implementation phase of the nursing process.

At the beginning of prenatal care, the goal for the client was to gain 25 lb (11.25 kg) by the end of the pregnancy. At 30 weeks of pregnancy, the client has only gained 1 lb (0.45 kg). Which statement(s) would help the nurse most appropriately interpret these data?

The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight. The client is not achieving the goal. The nurse should determine what the causes are in order to revise the plan of care. It is important to determine as early as possible if the plan of care is working. This will allow sufficient time to revise the plan of care. It is unrealistic to think the client will achieve the goal in the next 10 weeks. The client may not achieve the goal, but the priority at this time is to determine the reasons and revise the plan of care.

A nurse is evaluating nursing care and client outcomes by using a retrospective evaluation. Which action would the nurse perform in this approach?

The nurse devises a postdischarge questionnaire to evaluate client satisfaction. Evaluations can be conducted concurrent with care (conducted by using direct observation of nursing care, client interviews, and chart review to determine whether the specified evaluative criteria are met), or retrospective (postdischarge questionnaires, client interviews by telephone or face to face, or chart review to collect data).

Which nursing actions reflect the evaluation stage of the nursing process? Select all that apply.

The nurse identifies that a client's pain is not being adequately treated. The nurse documents the client's response to suctioning. The nurse determines the client did not lose the expected 2 lb (0.90 kg). Examples of evaluation include documenting the client's response to suctioning and making a judgment that the client did not reach the expected outcome of a 2-lb (0.90-kg) loss or adequate pain control. Setting an anxiety rating with the client is an example of planning. Performing tracheostomy care is an example of implementation.

A nurse is caring for a client in the immediate postoperative period and discovers there are factors that are affecting the attainment of client goals. Which statement is true of factors that influence client responses and outcome achievement? Select all that apply.

The nurse will draw on positive factors to deal with other variables in the future. A client's strong motivation to learn appropriate health behaviors is an example of a positive factor. The nurse should understand which factors are helpful to attaining outcomes and manipulate them to achieve goals. The nurse should reinforce positive behaviors to achieve the outcomes for the client. Positive and negative factors can be manipulated to improve client outcomes. The other choices are all true regarding positive factors.

The health care team has convened to discuss the care of an end-of-life client who is not able to achieve an acceptable level of comfort. The physician asks for the nurse's perspective of the situation. Which standard for establishing and sustaining healthy work environments does this action represent?

True collaboration True collaboration involves skilled communication, mutual respect, shared responsibility, and decision making among nurses and other health team members. Skilled communication requires health team members to communicate in a nonintimidating manner with colleagues, allowing all voices to be heard regarding a matter. Effective decision making ensures nurses are active, valued partners in making policy, directing and evaluating clinical care, and leading organizational operations.

A new mother is having difficulty breastfeeding her newborn infant. A goal was established stating the baby would be nursing every 2 to 3 hours by age 1 week. The mother presents to the follow-up center at 1 week and reports the she discontinued breastfeeding. The nurse evaluates the original goal as:

completely unmet. After collecting data, nurses form a comprehensive picture of the client's behavioral responses. The next activity is to make a judgment about goal attainment by comparing the client's actual behavioral responses to the predicted responses or predetermined outcome criteria developed in the planning phase.

The terms "criteria" and "standards" are often used interchangeably, but they actually have distinct definitions. "Measurable qualities, attributes, or characteristics that identify knowledge or health status" are known as:

criteria. Criteria are "measurable qualities, attributes, or characteristics that identify skill, knowledge, or health status." Standards are the "levels of performance accepted by, and expected of, nursing staff or other health team members." Evidence-based practice incorporates delivering nursing care that evidence supports as likely to result in meeting the expected client outcomes. Evaluation involves measuring how well the client has achieved the outcomes that were set forth in the plan of care.

The focus of a hospital's current quality assurance program is a comparison between the health status of clients upon admission and at the time of discharge. This form of quality assurance is characteristic of:

outcome evaluation. Outcome evaluation focuses on measurable changes in the health status of the client or the end results of nursing care. Whereas the proper environment for care and the right nursing actions are important aspects of quality care, the critical element in evaluating care is demonstrable changes in client health status. Process evaluation addresses performance expectations during the various stages of the nursing process. Structure evaluation addresses the environment of care. A nursing audit focuses on the review of records.

The nurse is assessing the client's behavioral response to a nursing intervention. This type of evaluation is known as:

outcome evaluation. Outcome evaluation, which focuses on the client and the client's function, is currently receiving a great deal of emphasis. Outcome evaluation determines the extent to which the client's behavioral response to nursing intervention reflects the desired client goal and outcome criteria.

A nurse must call a health care provider to request a prescription for a client who is experiencing pain unrelieved by the previous medication prescribed. When the nurse makes the call, the provider screams at the nurse and states, "Just do what the prescription says! I am not giving you another prescription for pain medication!" What is the best response by the nurse?

"Speaking to me that way is unacceptable. We should work together for the benefit of the client." The nurse should inform the health care provider that the response is inappropriate and that the nurse is entitled to respectful conversation. The behavior of the health care provider should also be reported. The major issue is client care and this should be a top priority for the health care team. The other responses do not deal with this situation to prevent the behavior occurring again.

The mother of an infant comes to the clinic and asks the nurse if the infant can eat bananas now. The outcome statement on the infant's plan of care states "The mother will explain proper nutrition for infants." This is an example of what type of outcome statement?

Cognitive Cognitive outcomes are related to achieving greater knowledge. Psychomotor outcomes are those that are related to new skill attainment. Affective outcomes are related to feelings and attitudes. Physical changes are related to actual body changes in the infant.

A client is about to leave the hospital after having surgery for a fractured left femur. It is now in a plaster cast. The client asks how long before the cast will be dry. The nurse notes on the client's plan of care a learning outcome stating "Client will verbalize appropriate cast care upon discharge." This represents what type of outcome?

Cognitive This is an example of a cognitive outcome. Cognitive outcomes are related to achieving greater knowledge. Psychomotor outcomes are those that are related to new skill attainment. Affective outcomes are related to feelings and attitudes. Physical changes are related to actual body changes in the individual.

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem?

Investigate the circumstances that contributed to client falls. The most effective method to address the increased frequency of client falls (and to promote a positive working environment) would be to determine the circumstances that contributed to the clients' falls. Attempting to identify and reprimand individual nurses does not lead to an atmosphere of openness and honesty in determining the causes. Instituting a new policy to prevent falls is premature before identifying why the falls are occurring. It may be relevant later to determine if other units are having the same problem, but it is not necessary at this time.

Prior to the first postoperative visit postgastrectomy, the client will have a weight loss of 10 lb (4.5 kg). This is an example of which type of evaluative statement?

Physical changes Physical changes are related to actual body changes in the individual, represented here by the 10 lb (4.50 kg) weight loss. Psychomotor outcomes are those that are related to new skill attainment. Cognitive outcomes are related to achieving greater knowledge. Affective outcomes are related to feelings and attitudes.

The mother brings her infant into the clinic. The infant is 2 months old and has not been gaining weight appropriately. The outcome statement on the plan of care states "The infant will double birth weight by 6 months of age." This is an example of what type of outcome statement?

Physical changes Physical changes are related to actual body changes in the infant. Psychomotor outcomes are those that are related to new skill attainment . Cognitive outcomes are related to achieving greater knowledge. Affective outcomes are related to feelings and attitudes.

Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement?

Psychomotor Psychomotor outcomes are those that are related to new skill attainment, such as learning aseptic dressing changes. Cognitive outcomes are related to achieving greater knowledge. Affective outcomes are related to feelings and attitudes. Physical changes are related to actual body changes in the individual.

The nurse is caring for a client who has a fractured left femur. The client will be discharged home this afternoon. The outcome on the plan of care states "Client will demonstrate cast care prior to discharge" What type of evaluative statement is this?

Psychomotor This is an example of a psychomotor evaluative statement. Psychomotor outcomes are those that are related to new skill attainment. Cognitive outcomes are related to achieving greater knowledge. Affective outcomes are related to feelings and attitudes. Physical changes are related to actual body changes in the individual.

A nurse just reported to the oncoming shift that she had failed to perform an ordered dressing change. She reported to the nurse manager that this was the second time this week she had not had time to do the dressing change. The nurse manager recognized that the nurse normally was very punctual and was known to provide good care for her clients. However, the unit census had been very high on this particular week. The nurse manager knows that quality care must be provided and reports this occurrence as what type of quality approach?

Quality by opportunity Quality by opportunity is focused on finding opportunity to improve quality through teamwork and sharing in a nonthreatening environment. Mistakes are seen as a breakdown in the system rather than a lack of motivation or sign of competence of the nurse.

Which expected client outcome is an example of a psychomotor outcome? Select all that apply.

Safely ambulating using a walker Accurately drawing up insulin Examples of psychomotor outcomes include accurately drawing up insulin and ambulating safely using a walker. Identifying signs and symptoms of infection is an example of a cognitive outcome. Rating pain as a 2 on a 0 to 10 scale is a physiologic outcome. An example of an affective outcome is reporting increased confidence in testing blood sugar.

Nurse Mayweather is auscultating lung sounds. She notes crackles in the LLL which were not present at the start of the shift. Nurse Mayweather is engaged in which type of nursing intervention?

Surveillance intervention Surveillance interventions include detecting changes from baseline data and recognizing abnormal response. Nurses rely on the senses to detect changes: observing the appearance and characteristics of clients; hearing by auscultation, pitch, and tone. Nurses use these surveillance activities to determine the current status of clients and changes from previous states.

A male client has been recently diagnosed with diabetes after receiving emergency treatment for a hyperglycemic episode. Which of the client's actions indicates that he has achieved a cognitive outcome in the management of his new health problem?

The client is able to explain when and why he needs to check his blood sugar. The ability to describe the rationale and technique for blood glucose monitoring indicates that the client has achieved a cognitive outcome. Demonstration of the technique constitutes a psychomotor outcome, while the expression of a desire for change is an affective outcome. The maintenance of healthy blood sugars is a physiologic outcome.

Which client outcome is an example of a physiologic outcome?

The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. Physiologic outcomes are physical changes in the client, such as pulse oximetry. An affective outcome involves changes in the client's values, beliefs, and attitude, such as engaging in exercise. Cognitive outcomes demonstrate increases in client knowledge, such as administration of a vaginal cream. Psychomotor outcomes describe the client's achievement of new skills, such as performing active range-of-motion exercises.

Which nurse is using criteria to determine expected standards of performance?

The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. Standards are the levels of performance accepted and expected by the nursing staff and other health team members, such as institutional policies and procedures. The nurse preceptor providing feedback to the new graduate nurse after 6 weeks of orientation is an example of peer review. The nurse manager providing the staff nurse feedback regarding job performance for the previous year is typical of an annual employee review.

A nurse evaluates clients prior to discharge from a hospital setting. Which action is the most important act of evaluation performed by the nurse?

The nurse evaluates the client's goal/outcome achievement. The priority is to evaluate the client's goal/outcome achievement. This determines if the nursing diagnosis has been resolved. If the client's goal/outcome had not been met the nurse should then begin evaluating all aspects of the plan of care. It is not the responsibility of the nurse to evaluate the competence of nurse practitioners. The nurse can evaluate services available to the client but this is not the purpose of the evaluation phase of the nursing process.

The nurse is conducting a peer review of a nursing colleague. Which action by the nurse is an example of peer review?

The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation. Peer review involves the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization for the purpose of professional performance improvement. The nurse preceptor providing feedback to the new graduate nurse after 6 weeks of orientation is an example of peer review.

The nurse in a Burn Intensive Care Unit (BICU) is caring for a 3-year-old boy who was burned with scalding hot water. He has burns covering 75 percent of his body. His condition is critical but stable. At 1000, the nurse reassesses the client and finds that he is agitated and pulling at his endotracheal tube. What would be the nurse's priority?

ensuring that the endotracheal tube is secure ABCs (Airway, Breathing and Circulation) are always top priority in client care. In this example, ensuring that the client maintains a patent airway will always be top priority. Each of these nursing tasks is important and will need to be accomplished at some point during client care.

After the nursing plan of care has been developed, the nurse knows that:

each encounter with the client is an opportunity to reassess and revise the plan of care if necessary. During each encounter with clients, nurses assess function, ensuring prompt attention to emerging problems. Because a client's condition can change quickly and dramatically, astute nurses remain alert to subtle cues and inferences. As they initiate the plan of care, nurses must ensure that the planned interventions are still relevant.

The nurse is caring for Mr. H., a 35-year-old man who is hospitalized following a motorcycle accident. He has a traumatic brain injury. The nurse is working with Mr. H. on self-care behaviors. The following would help the nurse to assess the success of the nursing interventions except which of the following?

Model self-care behaviors for the client. This question asks specifically about evaluation. Modeling self-care behaviors is an intervention, not an evaluation or assessment technique. When considering the responses, first check for sentence structure. Only one of the choices contains the three elements of the nursing diagnosis: the diagnostic label, the related factors, and the defining characteristics. The question asks for an actual diagnosis; this eliminates any risk, wellness, or potential diagnoses.

Which client outcome is a cognitive outcome? Select all that apply.

The client lists the side effects of digoxin. The client identifies signs and symptoms of hypoglycemia. The client describes how to perform progressive muscle relaxation. Cognitive outcomes demonstrate increases in client knowledge, such as listing side effects of medications, identifying signs and symptoms of hypoglycemia, and describing progressive muscle relaxation. A psychomotor outcome involves changes in the client's values, beliefs, and attitude. Psychomotor outcomes describe the client's achievement of new skills, such as correct ambulation with a walker. An affective outcome involves changes in the client's values, beliefs, and attitude, such as the client's report of cycling.

The nursing team created a plan of care for a client that requires a multidisciplinary approach due to the complex condition of the client. When evaluating the effectivenes sof the plan of care, what benefit of the evaluation process should the team keep in mind? Select all that apply.

to determine the client's responses to nursing interventions to appraise the extent to which client goals were attained to determine involvement and collaboration of the client, family members, nurses, and health care team members in health care decisions to collect subjective and objective data to make judgments about nursing care delivered Nurses always consider evaluation in light of how the client responded or reacted to the planned course of action. There are several purposes for carrying out evaluation: to examine the client's behavioral responses to nursing interventions; to compare the client's behavioral responses with predetermined outcome criteria; to appraise the extent to which client goals were attained or problems resolved; to appraise involvement and collaboration of the client, family members, nurses, and health care team members in health care decisions; to provide a basis for the revision of the plan of care evaluation; to collect subjective and objective data to make judgments about nursing care delivered; and to monitor the quality of nursing care and its effect on the client's health status. Specific activities during this phase include the following: reviewing client goals and outcome criteria, collecting data, measuring goal attainment, recording judgments or measurements of goal attainment, and revising or modifying the client's plan of care.