Fundamentals of Nursing Chapter 13 Outcome Identification and Planning – Flashcards
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A nurse assesses the vital signs of a patient who is one day postsurgery in which a colostomy was performed. The nurse then uses the data to update the patient plan of care. What are these actions considered?
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ongoing planning
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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?
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Seek research about the disorder.
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What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)?
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Nurses do carry out interventions in response to a physician's order.
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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?
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The nurse has omitted the time frame.
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The expected outcome for a client with a new diagnosis of diabetes mellitus (DM) is: client will describe appropriate actions when implementing the prescribed medication routine. Which statement by the client indicates the outcome expectation has been met?
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"I will test my glucose level before meals and use sliding scale insulin."
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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?
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Upon her admission to the hospital
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The nurse recognizes that an example of a cognitive outcome is:
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The client identifies three foods high in potassium by August 8.
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A nurse is demonstrating foley catheter care to a client. Which type of nursing intervention does this best represent?
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Educational
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When planning nursing interventions, the nurse must review the etiology of the problem statement. The etiology:
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Identifies factors causing undesirable response and preventing desired change
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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?
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A standardized care plan
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A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged 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?
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developing the plan without client input
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A nurse is planning nursing interventions for patients on a busy hospital ward. Which guideline would the nurse follow when designing the plan of care?
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Date the nursing interventions when written and when the plan of care is reviewed.
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The nurse is caring for a 48-year-old male patient with a new colostomy. Which patient goal for Mr. Conner is written correctly?
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Mr. Conner will demonstrate proper care of stoma by 3/29/15.
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Although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?
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Standardized
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When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?
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Psychomotor
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Which of the following actions are included in the planning process when a nurse is caring for an elderly client with AIDS?
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Identify measurable goals or outcomes
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A client was admitted two days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?
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Ongoing planning
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The nurse recognizes that identifying outcomes/goals must include:
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involvement of the client and family
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Which of the following is a correctly written nursing intervention? Select all that apply.
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• Provide 5 to 6 small meals daily. • Reposition the client from side to side every hour around the clock. • Provide opportunities for the client to express concerns and verbalize feelings.
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Which of the following outcomes is sufficiently measurable?
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Client will tolerate a full fluid diet with no complaints of nausea by 12/15/2011"
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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?
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"Please tell me your thoughts about treating this diagnosis.
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A nurse is giving post-operative care to a client after knee arthroplasty. Which of the following is a possible short-term goal for this client?
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To ambulate the client to a bedside chair
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Which intervention performed by the nurse is most appropriate for assisting a client in meeting physiologic needs based on Maslow's Hierarchy of Needs?
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Cutting up food and opening drink containers for the client.
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A nurse is caring for a client who began taking the antidepressant paroxetine (Paxil) 2 weeks ago. The client recently began giving away prized possessions and tells the nurse, "My mind is made up, I can do this." What is the best action by the nurse to incorporate this information into the plan of care?
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Add the nursing diagnosis: Risk for self-harm
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A client is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes?
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Family
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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?
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Client reports diarrhea
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The nurse understands which of the following are part of client-centered outcomes? Select all that apply.
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• 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.
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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(n)
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clinical pathway
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A nurse is using a structured care methodology that follows a set of steps based on a clinician's decision process to help standardize nursing care plans. What is the term for this element of a structured care methodology?
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algorithm
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Which of the following are verbs that are helpful in writing measurable outcomes? Select all that apply.
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• Define • Verbalize
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The nurse is considering the needs of the postoperative client in the home setting. The nurse is performing:
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Discharge planning
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The expected outcome for a client with a new diagnosis of osteoporosis is: client will implement actions to promote safety and bone strength. Which statement by the client is the best indicator that the outcome expectations have been met?
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"I walk daily wearing low-heeled shoes.
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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?
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Start from client's knowledge teach about diet modifications and check for learning.
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What are specific measurable and realistic statements of goal attainment?
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Outcome criteria
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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?
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Suggest the client use elastic shoe laces and pull clothes over leg with a grip extender.
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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?
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Client is normal tensive
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A nurse is planning care for an adult client with severe hearing impairment and a new diagnosis of cancer. What nursing action is most appropriate when establishing the plan of care?
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Arrange for an interpreter when discussing treatment.
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The nurse is prioritizing the client's nursing diagnoses. Which nursing diagnosis has the highest priority?
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Ineffective Airway Clearance related to retention of secretions
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Which nursing diagnosis is high priority?
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Ineffective breathing patterns
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The nurse is writing goals for patients being discharged from an acute care setting. Which goals are written correctly? (Select all that apply.)
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• By 4/5/15, the patient will demonstrate how to care for a colostomy. • After attending an infant care class, the patient will correctly demonstrate the procedure for bathing her newborn. • After counseling, the patient will describe two coping measures to deal with stress.
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A nurse is writing outcomes for patients in a rehabilitation facility. Which guidelines should the nurse consider? (Select all that apply.)
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• At least one of the outcomes the nurse writes should show a direct resolution of the problem statement in the nursing diagnosis. • The nurse should write outcomes that are brief and specific and support the overall plan of care.
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An older adult female client has been admitted to hospital for the treatment of exacerbation of chronic obstructive pulmonary disease. Which of the following statements constitutes a long-term outcome?
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The client will return home able to conduct her activities of daily living without experiencing shortness of breath.
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A broad, research-based practice recommendation that may or may not have been tested in clinical practice is:
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a guideline.
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A client with food poisoning has the nursing diagnosis "diarrhoea." Which expected client outcome most directly demonstrates resolution of the problem?
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Client will have formed stools within 24 hours
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A nurse is performing initial care planning for a hospitalized patient. Which actions occur during the initial planning of patient care? (Select all that apply.)
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• 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 patient goals and the related nursing care in the initial plan.
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When planning the care of a client who has been diagnosed with asthma, the nurse has written the following outcome: "Client will know how to self-administer his prescribed bronchodilators using a nebulizer by 09/09/2015." Why is this outcome inadequate?
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The outcome is not observable or measurable.
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A nurse is using the SMART acronym to plan outcomes for patients in a long-term care facility. Which criteria describe the use of this acronym? (Select all that apply.)
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• S = goals should be specific • M = goals should be measurable • R = goals should be realistic • T = goals should be temporary
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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?
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Include the client and the client's power of attorney in the discussion.
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Which is an appropriate expected outcome for a client?
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Client will ambulate safely with walker in the room within three days of physical therapy.
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A client stops in the hall after walking 30 feet and tells the nurse, "I don't want to do anymore exercise because I hurt too much." What is the next action the nurse should implement?
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Return the client to bed and provide pain relief measures.
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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?
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Encourage hourly use of the incentive spirometer.
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In what order will the nurse caring for a client with hemiparesis following cerebral vascular accident (CVA) prioritize these nursing diagnoses?
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Impaired urinary elimination Self-care deficit: dressing Sexual dysfunction Risk for social isolation
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According to the Nursing Intervention Classification (NIC), the most basic level of nursing intervention is:
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Physiologic
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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:
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condition.
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The nurse is planning care for a client with an open wound following surgery for a ruptured appendix. What short-term client goals help prepare the client for discharge? Select all that apply.
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• Client will increase nutrition, eating 75% of meals. • Client will report pain is controlled at or below 3 of 10. • Client will perform dressing change independently.
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A nurse is planning care for a patient who has just been diagnosed with type 2 diabetes. Which nursing action is performed during the planning step of the nursing process?
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The nurse selects nursing measures, including patient teaching
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The nurse is developing outcomes for the care plan of a patient admitted with Parkinson's disease. The nurse will derive the outcomes for this patient's care plan from:
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the problem statement of the nursing diagnosis.
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The nurse is assessing a group of clients who were brought into the emergency department after a motor vehicle accident that resulted in a fire. Which client should the nurse give the highest priority for care?
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A 45-year-old man with burns to his upper arms and chest and soot on his face who is restless and anxious
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A nurse designs a care plan to improve walking mobility in an older adult client. When encouraged 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?
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developing the plan without client input
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The nurse is planning care for a college student with a new diagnosis of inflammatory bowel disease. The client lives in the dormitory on campus and eats meals in the cafeteria. Which is the most appropriate long-term client outcome?
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Client will maintain nutritional intake without pain or diarrhea.
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A 63-year-old client in the ICU 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 her left side she notices that the client has a non-blanching reddened area over her right trochanter. What would be the most appropriate action for the nurse to take?
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The nurse repositions the client to her left side and updates the plan of care to turn and reposition the client every hour.
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Which statement correctly describes a nurse-initiated intervention?
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Nurse-initiated interventions are derived from the nursing diagnosis
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A client with multiple leg fractures following a motor vehicle accident tells the nurse, "I am going crazy here. I have to wait 2 months before I can practice walking, again." What is the highest priority nursing diagnosis?
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Deficient diversional activity
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A home care client with dementia has the nursing diagnosis "wandering." Which expected client outcome most directly demonstrates resolution of the problem?
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Client will not leave the premises without a caregiver.
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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?
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Start from client's knowledge teach about diet modifications and check for learning.
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A client is brought to the emergency department. The client is unkempt, reports being too busy to eat, and paces in the examination room stating there is no time to sit for treatment. Which nursing diagnosis will the nurse rank as the highest priority for this client?
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Ineffective impulse control
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A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:
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intervention
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A nurse is writing goals for a client who is scheduled to ambulate following hip replacement surgery. What is a correctly written goal for this client?
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Over the next 24-hour period, the client will walk the length of the hallway assisted by the nurse.
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A nurse reviews the client outcomes written by a student nurse. Which outcome requires modification?
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By the end of instruction, client will know how to perform dressing changes.
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The nurse is aware that basic patient needs must be met before a patient can focus on higher ones. According to Maslow's hierarchy of human needs, which example would be the highest priority for a patient after physiologic needs have been met?
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Grab bars are installed in a patient bathroom to facilitate safe showering.
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A father runs into the emergency room with his 18-month-old son in his arms. The father screams, "Help, he is not breathing!" The nursing diagnosis of Impaired Gas Exchange is what level of priority diagnosis?
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high priority
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The nurse, in collaboration with the client's family, is assigning priorities related to the care of the client. The nurse explains that when setting priorities it is important to look at the urgency of specific problems. What provides the best framework for prioritizing client problems?
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Maslow's hierarchy of needs
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A nurse is formulating a nursing plan of care for a client based on assessment data. When writing this plan, which would be most important for the nurse to include?
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Nursing interventions
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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?
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Perform hourly neurovascular assessment
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The nurse recognizes that an example of a cognitive outcome is
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The client identifies three foods high in potassium by August 8.
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The nurse is writing client outcomes for a newly admitted client with alcohol withdrawal. Which outcome is the highest priority?
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Within 48 hours, client will recognize when additional tranquilizers are needed.
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The nurse is writing a measurable outcome for a patient with a new prosthesis to begin walking again. Which components must be included in the outcome? (Select all that apply.)
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• The action the patient will perform • Particular circumstances in which the outcome is to be achieved • The patient or some part of the patient • Target time when the patient is expected to be able to achieve the outcome
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A client with end-stage chronic obstructive pulmonary disease (COPD) has the nursing diagnosis "activity intolerance." Which expected client outcome most directly demonstrates resolution of the problem?
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Client will alternate rest periods with exercise through the day.
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Which is an appropriate expected outcome for a client undergoing treatment for ovarian cancer?
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By discharge, client will perform hand hygiene before and after port care.
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For which of the following patients would a standardized plan of care most likely be appropriate?
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A patient who was admitted for shortness of breath and who has been diagnosed with pneumonia
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A nurse writes down the following outcome for a depressed client: "By 6/9/12, the client will state three positive benefits of receiving counseling." This is an example of which of the following types of outcomes?
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Affective
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Which nursing diagnosis will the nurse rank as the highest priority for premature newborn twins?
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Altered gas exchange
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A nurse is planning care for patients in a physician's office. Which actions will the nurse perform during this step of the nursing process? (Select all that apply.)
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• Establishing priorities • Identifying expected patient outcomes • Selecting evidence-based nursing interventions • Communicating the plan of nursing care
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The nurse is caring for a client who is undergoing treatment for infertility caused by endometriosis. Which of the following outcome statements is structured correctly?
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By discharge from the clinic, client will achieve full-term pregnancy.
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The nurse is writing care plans for clients in the team. Which is an appropriate expected outcome for a client?
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Client will independently follow transplant medication schedule 1 week after surgery.
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Which of the following reflect planning? Select all that apply.
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• The nurse considers the developmental level of the client when selecting teaching materials. • The nurse seeks input from the client and family regarding acceptable non-pharmacological pain management strategies. • The nurse decides to assist the client with ambulation in the hallway twice a shift.
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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?
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Include the client and the client's power of attorney in the discussion.
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These nursing diagnoses appear on a client's care plan. In what order will the nurse prioritize them?
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Impaired swallowing Fluid volume deficit Risk for impaired skin integrity Altered body image
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A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "impaired swallowing." Which expected client outcome is most effective?
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Client will use chin tuck and double swallow for each bite.
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The nursing student asks the nurse about nurse-initiated and physician-initiated interventions. Which of the following is a nurse-initiated intervention?
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Teach client how to splint abdominal incision when coughing and deep breathing.
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After the health history and admission assessment are completed the nurse establishes a care plan for the patient. What is the rationale for documenting and planning the patients' care?
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It helps deliver holistic, goal-oriented, individualized care.
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A nurse administers clonidine (Catapres) according to the standardized plan of care for a client admitted with hypertension. Which assessment information deviates from the expected client outcome for the first 24 hours and requires nursing intervention?
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Client gains 1 kg (2.2 lb) in 1 day
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A nurse is caring for an overweight, highly stressed 50-year-old male executive who is being discharged from the hospital after undergoing coronary bypass surgery. What is an affective goal for this patient?
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By 6/30/15, the patient will reduce the cholesterol in his diet.
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A client is required to be 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?
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Updating the diet orders in the client's plan of care.
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A client with a right facial droop and dysphagia after a stroke has the nursing diagnosis "impaired swallowing." Which expected client outcome is most effective?
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Client will use chin tuck and double swallow for each bite
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A nurse plans a series of muscle strengthening activities to help a client with amyotrophic lateral sclerosis (ALS) regain the ability to walk. The client is unsuccessful when the new strategies are implemented. What action by the nurse may have led to failure to meet the outcome?
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Choosing actions that do not solve the problem
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Which of the following is categorized as a psychomotor outcome?
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Within two days of education, the client's wife will demonstrate abdominal dressing change.
