Nurse 3010 Foundations of Professional Practice Chapter 16: Outcome Identification and Planning

These nursing diagnoses appear on a client's care plan. In what order will the nurse prioritize them?

Impaired Swallowing Fluid Volume Deficit Risk for Impaired Skin Integrity Altered Body Image

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?

Narcotic analgesic to treat pain

Which statement correctly describes a nurse-initiated intervention?

Nurse-initiated interventions are derived from the nursing diagnosis.

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

Nursing Outcome Classification system

Which elements are common to any type of plan of care? Select all that apply.

Nursing diagnoses Client goals Nursing interventions

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."

The nurse reviews an interdisciplinary plan of care to determine the day's care guidelines and outcomes for a client who had a left hip replacement. The type of plan of care the nurse is reviewing is:

A clinical Pathway. Helps with standardized, interdisciplinary care.

Which client outcome requires modification?

By the end of instruction, client will know how to perform dressing changes.

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

Physiological.

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.

Which outcome is sufficiently measurable?

Client will tolerate a full fluid diet with no reports of nausea by 12/15/2020.

A client has terminal cancer and the primary care provider has ordered a diagnostic imaging test. The client does not want the test performed so the nurse agrees to dialogue with the primary care provider on the client's behalf. The nurse's actions are what type of intervention?

Coordination. Coordination is more closely associated with client advocacy.

Which action should the nurse perform during the planning step of the nursing process?

Selects nursing measures, including client education

The nurse recognizes that an example of a cognitive outcome is:

The client identifies three foods high in potassium by August 8.

Which is an example of a psychomotor outcome?

Within 2 days of education, the client's spouse will demonstrate an abdominal dressing change.

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

discharge planning.

The client tells the nurse, "I think the nurse last night may have given me the wrong medication, but I was afraid to say anything." What is the nurse's most appropriate response?

"You should always speak up if you have any questions about your care."

For which client would a standardized plan of care most likely be appropriate?

A client who was admitted for shortness of breath and who has been diagnosed with pneumonia. Client's who have specific and common health problems are more likely to receive standardized care. Clients with unknown, or numerous pathologies are unlikely to have their health care needs met by standardized plans.

Which type of nursing intervention is oxygen administration and why is it considered to be so?

A dependent nursing intervention, because oxygen is considered a drug that requires a physician's order

Which examples of nursing actions involve direct care of the client? Select all that apply.

A nurse counsels a young family who is interested in natural family planning. A nurse massages the back of a client while performing a skin assessment. A nurse helps a client in hospice fill out a living will form.

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

A nurse in the intensive care unit (ICU) has been assigned to care for a client who was seriously injured during a gang rape. The nurse was raped 6 months ago and fears being too upset to care for the client properly. How should the nurse deal with the assignment?

Recognize the nurse's own limitations and ask for another nurse to be assigned. The nurse wouldn't want for her possible emotional breakdown to disrupt client 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.

The nurse understands that which are part of client-centered outcomes? Select all that apply.

The outcome demonstrates resolution of the nursing problem. Long-term outcomes may be used as discharge goals. Expected client outcomes are used to evaluate achievement. Goals and outcomes are interchangeable.

The nursing is caring for several clients. Which intervention can the nurse direct the unlicensed assistive personnel (UAP) to perform?

Bathe a client with stable angina who has a continuous IV infusing.

A nurse is preparing to educate a client about self-care after cataract surgery. Which should the nurse do first?

Determine the client's willingness to follow the regimen.

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

A client in the intensive care unit with a nursing diagnosis of Risk for Impaired Skin Integrity has a nursing intervention that states the client is to be turned and repositioned every 2 hours. As the nurse is turning the client to the client's left side, the nurse notices that the client has a nonblanching, reddened area over the right trochanter. What would be the most appropriate action for the nurse to take?

The nurse repositions the client to the client's left side and updates the plan of care to turn and reposition the client every hour.