nur process outcomes and goals

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin.

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 normal tensive

Which is an appropriate expected outcome for a client?

Client will ambulate safely with walker in the room within 3 days of physical therapy Outcomes should be specific, measurable, attainable, realistic, and timebound. Safe ambulation after several days with physical therapy is a specific and reasonably attainable goal. Common errors to avoid when writing outcomes are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, using verbs that are not observable, and using verbs that are not measurable such as "know" and "understand

A home care client with dementia has the nursing diagnosis "Wandering." Which expected client outcome most directly demonstrates resolution of the problem?

Client will not leave the premises without a caregiver

A computerized information system developed to classify client outcomes is the:

Nursing Outcome Classification The Nursing Outcome Classification (NOC) system is organized according to categories, classes, labels, outcome indicators, and measurement activities for outcomes

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?

Scientific rationales

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

The nurse recognizes that an example of a cognitive outcome is

The client identifies three foods high in potassium by August 8

An older adult female client has been admitted to the hospital for the treatment of exacerbation of chronic obstructive pulmonary disease (COPD). Which statement constitutes a long-term outcome?

The client will return home able to conduct her activities of daily living (ADLs) without experiencing shortness of breath.

The nurse has identified the following outcome for the client: The client will have a soft formed stool. Which error has the nurse made in writing the outcome?

The nurse has omitted the time frame.

A nurse is reviewing the outcome criteria that were developed for a client. The nurse determines that the criteria are appropriate because which characteristic is met? Select all that apply

can be measured are specific are realistic

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

intervention. A nursing intervention is any treatment based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes.

The nurse is developing outcomes for the care plan of a client admitted with Parkinson's disease. The nurse will derive the outcomes for this client's care plan from:

the problem statement of the nursing diagnosis

The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply.

After attending an infant care class, the client will correctly demonstrate the procedure for bathing her newborn. By 4/5/15, the client will demonstrate how to care for a colostomy. After counseling, the client will describe two coping measures to deal with stress.

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis

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.

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

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

The nurse is caring for Isabel, a 45-year-old ventilator-dependent quadriplegic. The nurse is in the process of placing IV access when the ventilator alarms occlusion. The nurse assesses Isabel and she appears mildly uncomfortable but is not in acute distress. What is the nurse's priority in the nursing outcome planning?

Assess tracheostomy for patency

The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:

Discharge planning Discharge planning begins at the time of admission with the nurse teaching the client and family specific knowledge and 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 nurse assesses the vital signs of a client who is one day postoperative in which a colostomy was performed. The nurse then uses the data to update the client plan of care. What are these actions considered?

Ongoing planning Ongoing planning is carried out by any nurse who interacts with the client. Its chief purpose is to keep the plan up-to-date to facilitate the resolution of health problems, manage risk factors, and promote function. The nurse caring for the client uses new data as they are collected and analyzed to make the plan more specific and accurate and, therefore, more effective.

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." How does the nurse interpret this statement?

Outcome criteria This statement is an example of outcome criteria. Outcome criteria answer the questions who (the client), what actions (verbalizes), under what circumstances (to the staff), how well (accurately), and when (before discharge). Nursing diagnosis would include a diagnostic label, related factors and defining characteristics. Intervention would reflect an action or treatment performed to promote client outcomes. The client has not met the outcome at this point in order to evaluate.

According to the Nursing Intervention Classification (NIC), the most basic level of nursing intervention is

Physiologic The most basic domain of the seven domains of Nursing Intervention Classifications is Physiologic: Basic. pg 286-287

A client is required to be n.p.o. 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

A nurse is caring for a client who began taking the antidepressant paroxetine 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can't do this any longer." What is the best action by the nurse to incorporate this information into the plan of care?

Add the nursing diagnosis: Risk for Self-Harm.

A 16-year-old client was admitted to the medical unit 1 hour ago for sickle cell crisis. Vital signs are as follows: T: 36.8°C sublingual, HR: 95, RR: 20, BP: 130/65. The client rates pain as a 9/10. The nurse is talking with the medical resident on service to discuss client orders. What order is the nurse likely to request first for the client?

Narcotic pain medication to treat pain A sickle cell crisis is an extremely painful event. Most clients with sickle cell have an individualized narcotic plan that will help them to receive narcotics in an expedited manner when they present in crisis. The slight elevation in the client's BP and HR are likely secondary to pain. There is no evidence of respiratory illness based on the information given. Acetaminophen is not strong enough to treat pain; furthermore, the client does not have a fever.

A nurse is working with a client who is having a difficult time accepting her new diagnosis of type II diabetes. The nurse pulls up a chair next to the client's bed and holds her hand while listening to her story. What type of nursing intervention is the nurse engaging in?

Supportive intervention Supportive interventions emphasize use of communication skills, relief of spiritual distress, and caring behaviors. Psychosocial interventions focus on resolving emotional, psychological, or social problems. Coordinating interventions involve many different activities such acting as a client advocate, and making referrals for follow-up care. Supervisory interventions refer to overseeing the client's overall healthcare.

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 her activities of daily living (ADLs) during her period of recovery. When should discharge planning to address ADLs begin for this client?

Upon her admission to the hospital