Chapter 15: Evaluating

question

Which statement related to the evaluation of outcome attainment for a client is correct? Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria. The nurse should initially evaluate the plan of care at the time of the client’s discharge. Celebrating outcome achievement with a client often interferes with attainment of future goals. Evaluation of the client’s attainment of outcome goals is determined by the nurse and physician.
answer

Collecting data related to outcome attainment requires the nurse to know when to collect the data, based upon established time criteria. In addition to knowing what type of data to collect to determine outcome achievement, it is important to know when to collect the data based upon established time criteria. It is important for the nurse to evaluate client outcome achievement as early as possible and not wait until discharge, when the plan of care cannot be modified. Evaluation of the client’s attainment of outcome goals is determined by the nurse, client, and the client’s family. Celebrating outcome attainment with the client usually helps encourage the client and leads to further outcome achievement.
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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 client can demonstrate the correct technique for using his new glucometer. The client’s blood sugars have been maintained within acceptable range in the days prior to discharge. The client expresses a desire to change the way that he eats and the amount of exercise he performs.
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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.
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One of the outcomes that has been identified in the care of a client with a new suprapubic catheter is that he will demonstrate the correct technique for cleaning his insertion site and changing his catheter prior to discharge. When should this outcome be evaluated? throughout the client’s hospital admission when the client is discharged during the first home health care visit once the primary care physician has written a discharge order
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throughout the client’s hospital admission
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The primary purpose for evaluating data about a client’s care according to a functional health approach is to: meet accreditation standards. determine implementation of medical orders. evaluate the need for health care consultations. revise or modify the patient care plan.
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revise or modify the patient care plan. Evaluation using the functional health approach provides a framework for organizing and evaluating data.
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Which nurse is using criteria to determine expected standards of performance? The nurse manager provides the staff nurse feedback regarding job performance for the previous year. The nurse seeks information from the unlicensed assistive personnel (UAP) regarding the family’s response to the nurse’s education. The new graduate nurse consults the policies and procedures of the institution prior to skill implementation. The nurse preceptor provides feedback to the new graduate nurse after 6 weeks of orientation.
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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.
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Which nursing action reflects evaluation? The nurse identifies that the client has wound drainage. The nurse sets an anxiety level of 3 or less with the client. The nurse performs a colostomy irrigation. The nurse assesses the client’s response to pain medication.
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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.
question

The client identifies three strategies for minimizing leakage of an ileostomy bag. This is an example of what type of outcome? Affective outcome Psychomotor outcome Physiologic outcome Cognitive outcome
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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.
question

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. the plan will be followed by other health care providers and filed with the client’s chart upon discharge. the responsibility for the assessment of the client has ended. care plans are rigid and do not change. the plan of care can only be changed by the nurse who developed it.
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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.
question

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? It is too early to evaluate if the goal has been achieved. The client has 10 more weeks of pregnancy. The client is not achieving the goal. The nurse should determine the reasons the client has not been gaining weight. The client is progressing toward achieving the goal. The plan should be continued. The client has partially achieved the determined goal. The nurse should revise the goal to reflect a more realistic outcome.
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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.
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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? Reprimand the nursing personnel responsible for the clients when the falls occurred. Investigate the circumstances that contributed to client falls. Institute a new policy on the prevention of client falls on the unit. Determine if client falls have increased on other units in the hospital.
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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.
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A nurse is evaluating the plan of care for a client in the clinic. Which actions will she perform as a classic element of evaluation? Select all that apply. identifying evaluative criteria and standards documenting only the facts related to the plan of care collecting data to determine if criteria or standards are being met interpreting and summarizing findings terminating, continuing, or modifying the plan of care
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-identifying evaluative criteria and standards -collecting data to determine if criteria or standards are being met -interpreting and summarizing findings -terminating, continuing, or modifying the plan of care The nurse must document findings as they relate to the plan of care but should also include the nurse’s judgement as to whether the outcomes are being met. All of the other choices are criteria for evaluation.
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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: criteria. evaluation. standards. evidence-based practice.
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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.
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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 which of the following? Criteria Evaluative statement Standard Evidence-based practice
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Evaluative statement An evaluative statement is a statement summarizing the client’s outcome achievement. Criteria are “measurable qualities, attribute, 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 patient outcomes.
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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 infants plan of care states “The mother will explain proper nutrition for infants.” this is an example of what type of outcome statement? Psychomotor Cognitive Affective Physical changes
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Cognitive 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 and physical changes are related to actual body changes in the infant.
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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 his plan of care a learning outcome stating “Client will verbalize appropriate cast care upon discharge.” This represents what type of outcome? Psychomotor Cognitive Affective Physical change
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Cognitive This is an example of a cognitive outcome. 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.
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Before discharge the client will demonstrate aseptic dressing changes. This is an example of which type of evaluative statement? Psychomotor Cognitive Affective Physical changes
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Psychomotor 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 and physical changes are related to actual body changes in the individual.
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Prior to the first postoperative visit post gastrectomy, the client will have a weight loss of 10 lb (4.50 kg). This is an example of which type of evaluative statement? Cognitive Psychomotor Physical changes Affective
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Physical changes 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 and physical changes are related to actual body changes in the individual which is represented by the 10 lb (4.50 kg) weight loss.
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Nurses formulate different types of goals for clients when planning client care. What is considered a psychomotor client goal? By 18AUG2015, client will value his health sufficiently to quit smoking. By 18AUG2015, client will demonstrate improved motion in left arm. By 18AUG15, client will list three foods that are low in salt. By 18AUG2015, client will learn three exercises designed to strengthen leg muscles.
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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.
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The nurse is working with Ms. V. today. Ms. V. is having a difficult time accepting her new diagnosis of type 2 diabetes. Thenurse pulls up a chair next to Ms. V.’s bed and holds her hand while listening to her story. What type of nursing intervention is the nurse engaging in? Supportive intervention Psychosocial intervention Coordinating intervention Supervisory intervention
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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 as acting as a client advocate and making referrals for follow-up care. Supervisory interventions refer to overseeing the client’s overall health care.
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The purpose of the nursing intervention classification (NIC) is which of the following? Select all that apply. creation of a standardized language assistance in determining the cost of services that nurses provide demonstration of the impact of nurses to create busy work for the nursing professional
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-creation of a standardized language -assistance in determining the cost of services that nurses provide -demonstration of the impact of nurses Additionally, the NIC helps to expand the knowledge of similarities and differences across nursing diagnoses and explore nursing care information systems.
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The nurse reports for a day shift and learns that the unit is understaffed due to several sick calls. The charge nurse has arranged for two unlicensed assistive personnel to be available due to the nursing shortage on this morning. The nurse is aware that this shortage has the potential to affect the nursing care delivered on the unit on this day. What type of variable has the nurse identified as potentially affecting the care delivery? Healthcare system variable Patient variable Nurse variable Legal variable
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Healthcare system variable Numerous patient, nurse, and healthcare system variables contribute positively or negatively to patient outcome achievement. The nurse has determined that a healthcare system variable, such as inadequate staffing, has the potential to negatively affect the nursing care delivered.
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The nurse manager on an orthopedic unit has determined that the nurses are not keeping the nursing diagnoses up-to-date on client care plans and, in turn, are not using the plan of care. What is a feasible approach to correcting this problem? Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses. Request that a staff development nurse instruct the nurses on concept mapping to use instead of care planning. Provide an in-service on interviewing and physical assessment skills; discuss the importance of these skills with the staff. Delegate the updating of nursing diagnoses for all clients on the unit to one nurse for each shift.
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Develop a process for periodic review of care plans that focuses on deleting and updating the nursing diagnoses. Upon recognizing that the nursing diagnoses are not up-to-date, an effective approach by the nurse manager is to establish a process for periodic review of the plan of care. This review process will require deletion of nursing diagnoses that have been resolved and, conversely, adding new diagnoses as needed. Implementing concept mapping will not correct the problem of poorly updated nursing diagnoses, as concept mapping requires the identification of nursing diagnoses. Developing interviewing and assessment skills is an important component of the assessment phase of the nursing process. Also, one nurse should not be responsible for updating nursing diagnoses for all client care plans on the unit.
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Which client outcome is a cognitive outcome? Select all that apply. The client lists the side effects of digoxin (Lanoxin). The client describes how to perform progressive muscle relaxation. The client identifies signs and symptoms of hypoglycemia The client correctly ambulates with a walker. The client reports cycling 30 minutes three times each week.
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-The client lists the side effects of digoxin (Lanoxin). -The client describes how to perform progressive muscle relaxation. -The client identifies signs and symptoms of hypoglycemia. 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.
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The nurse participates in a quality assurance program and reviews evaluation data for the previous month. The data indicates a nursing plan was developed within 8 hours of admission for 97% of all admissions. The nurse recognizes this as which type of evaluation? Design evaluation Outcome evaluation Structure evaluation Process evaluation
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Process evaluation Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Process evaluation focuses on the nature and sequence of activities carried out by nurses implementing the nursing process, such as the timing of nursing care plan creation. Outcome evaluation focuses on measurable changes in the health status of clients. Structure evaluation focuses on the environment in which care is provided. There is no “design evaluation.”
question

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. The client reports walking for 30 minutes each day. The client demonstrates active range of motion exercises with left upper extremity. The client explains how to administer a vaginal cream.
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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.
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Which statements describe the purpose of evaluation? Select all that apply. to examine the client’s behavioral responses to nursing interventions 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 ensure the plan of care was followed as it was origninally prepared to collect subjective and objective data to make judgments about nursing care delivered
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-to examine the client’s behavioral responses to nursing interventions -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 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.
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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: process. outcome. goal. subjective. structure.
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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.
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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: met. partially met. completely unmet. inappropriately chosen for this client.
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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.
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Which of the following actions should the nurse take during the evaluation phase of the nursing process? Document improved pain after pain medication administered Provide client with follow-up appointment after discharge Have client give input into plan of care upon admission Discontinue indwelling urinary catheter per provider’s order
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Document improved pain after pain medication administered Documenting improved pain after pain medication is an evaluation of pain relief after an intervention. 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.
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Nurses are involved in many types of evaluation. All of the following are activities that are related to evaluation, but which of the following is the priority concern for nurses? Measuring patient outcome achievement Helping targeted groups of patients to achieve their specific outcomes Measuring the competence of individual nurses Patients and their care
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Patients and their care The priority concern for nurses should always be related to care of patients. The other choices are all activities related to evaluation but are not the priority.
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Which of the following would a nurse know is a part of an evaluative statement? Select all that apply. Description of how the patient outcome was met Client’s health history Name of client’s physician Patient data that supports how the outcome was met
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-Description of how the patient outcome was met -Patient data that supports how the outcome was met An evaluative statement includes a description of how the patient’s outcome was met and the data that supports that decision. The name of the physician and the health history would only be included if it contributed to the patient’s outcome.
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The mother brings her infant into the clinic. The infant is two 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? Psychomotor Cognitive Affective Physical changes
answer

Physical changes 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 and physical changes are related to actual body changes in the infant.
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The nurse is caring for a client who has a fractured left femur. He will be discharged home this afternoon. The outcome on the plan of care state “Client will demonstrate appropriate cast care prior to discharge” This is an example of what type of evaluative statement? Psychomotor Cognitive Affective Physical changes
answer

Psychomotor 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 and physical changes are related to actual body changes in the individual.
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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? Report the nurse applying the restraints to the supervisor. File an incident report and have the second nurse sign it. Confront the nurse and explain how this could be dangerous for the client. Contact the physician for an order for the restraints.
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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.
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A nurse is evaluating nursing care and patient outcomes by using a retrospective evaluation. Which action would the nurse perform in this approach? The nurse directly observes the nursing care being provided. The nurse reviews the patient chart while the patient is being cared for. The nurse interviews the patient while he or she is receiving the care. The nurse devises a post-discharge questionnaire to evaluate patient satisfaction.
answer

The nurse devises a post-discharge questionnaire to evaluate patient satisfaction. Evaluations can be conducted concurrent with care (conducted by using direct observation of nursing care, patient interviews, and chart review to determine whether the specified evaluative criteria are met), or retrospective (postdischarge questionnaires, patient interviews by telephone or face to face, or chart review to collect data).
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Nurses formulate physiologic goals for patients when providing patient care. What are examples of physiologic goals? (Select all that apply.) By 4/6/15, the baby will demonstrate adequate sleep-wakefulness patterns. Before discharge, the parents of the baby will verbalize decreased anxiety about taking care of a newborn. By 4/6/15, the parents will list appropriate resources in case questions arise after discharge. By 4/6/15, the baby will show an adequate comfort level indicating satisfactory parenting. Before discharge, the baby will have reached a target weight gain of 8 lb (birth weight: 7 lb, 6 oz). Before discharge, the parents will demonstrate confidence in bathing and feeding their baby.
answer

-By 4/6/15, the baby will demonstrate adequate sleep-wakefulness patterns. – By 4/6/15, the baby will show an adequate comfort level indicating satisfactory parenting. -Before discharge, the baby will have reached a target weight gain of 8 lb (birth weight: 7 lb, 6 oz). Physiologic goals meet the need of normal, healthy body functioning. An infant’s sleep-wake patterns, comfort level, and weight are all examples of physiologic goals/outcomes. Decreased anxiety of the parents and demonstration of confidence in bathing their baby is an affective outcome. Listing appropriate resources demonstrates cognitive goals.
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When recording or documenting outcome attainment in the chart, nurses are to be very clear with the descriptions used. Which term is appropriate? “Inadequate skills” “Great response” “Extremely well-mannered” “Demonstrated steps”
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“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.
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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? Process evaluation Structure evaluation Outcome evaluation Cost-effectiveness evaluation
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Outcome evaluation An outcome evaluation determines the extent to which a client’s behavioral response to a nursing intervention reflects the outcome criteria.
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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? Educational intervention Psychomotor intervention Maintenance intervention Surveillance intervention
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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.
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Nurse Sanchez is a community health nurse in a largely Hispanic community. She has noticed that a large percentage of her clients with type 2 diabetes struggle to find food choices that are a compatible with the cooking style of their culture. Nurse Sanchez decides to organize a cooking class to demonstrate to clients with type 2 diabetes how to prepare culturally appropriate foods. Nurse Sanchez’s actions could be labeled as what types of nursing interventions? Select all that apply. Educational intervention Psychosocial intervention Supervisory intervention Supportive intervention
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Educational intervention Psychosocial intervention Supervisory intervention Nurse Sanchez is exhibiting educational intervention as she is demonstrating to her clients how to prepare appropriate foods; She is also exhibiting psychosocial intervention in that she is focusing on resolving her clients cultural and social views on preparing foods that may not be healthy. Nurse In addition, Nurse Sanchez is exhibiting supervisory intervention in that she is overseeing and encouraging client changes regarding diet.
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Which client outcome is a psychomotor outcome? Select all that apply. The client identifies five low sodium foods. The client describes how to empty a Jackson-Pratt drain. The client measures capillary blood sugar level. The client catheterizes self, using clean technique. The client reports imagery is effective in controlling anxiety.
answer

-The client measures capillary blood sugar level. -The client catheterizes self, using clean technique. Psychomotor outcomes describe the client’s achievement of new skills, such as measuring capillary blood sugar and self-catheterization. Cognitive outcomes demonstrate increases in client knowledge, such as identifying low sodium foods and describing how to empty a wound drain. An affective outcome involves changes in the client’s values, beliefs, and attitude, such as using imagery to control anxiety.
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Identifying the kind and amount of nursing services required is a possible solution for: Inadequate staffing. Clients who fail to communicate their needs. Nurses who are bored. Nurses frustrated with substandard care.
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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, while educating the client to become an assertive healthcare 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.
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Which of the following nursing actions reflects evaluation? The nurse identifies that the client does not tolerate activity. The nurse sets a tolerable pain rating with the client. The nurse auscultates the client’s lungs and abdomen. The nurse assesses urine output following administration of a diuretic.
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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.
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A nurse identifies an area where client care has been compromised. Which of the following steps should the nurse take to improve performance? Select all that apply. Plan a strategy using indicators Assess the change Discover a problem Ask the client if there is a problem Implement a change
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Plan a strategy using indicators Assess the change Discover a problem Implement a change Clients are not always aware of problems on a clinical unit. For example, if blankets are not being supplied to the unit per facility policy the client may not be aware because the nurse went and got one from another unit; however, there is a problem that should be addressed. The other choices are all part of the process to improve performance.
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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 of the following 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. The nurse will reinforce negative behaviors to achieve desired outcomes. A client’s strong motivation to learn appropriate health behaviors is an example of a positive factor. Only positive factors are used to manipulate client outcomes. The nurse should understand which factors are helpful to attaining outcome attainment and manipulate them to achieve goals.
answer

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 outcome attainment 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.
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A nurse is evaluating the plan of care for a client and determines that the achievement of goals is difficult to evaluate. Which of the following might the nurse do in evaluating the plan to see that the outcomes are correctly written? Select all that apply. Be sure that the criteria for appropriate response are clearly specified. Be certain that the subject is the client or some part of the client. See if the client’s expected behavior is written in observable, measurable terms, Rewrite the plan of care so that the client meets the expected outcomes. Specify time limits in the plan.
answer

-Be sure that the criteria for appropriate response are clearly specified. -Be certain that the subject is the client or some part of the client. -See if the client’s expected behavior is written in observable, measurable terms, -Specify time limits in the plan. The nurse would not rewrite the plan of care just so the client meets the outcomes. It should be ascertained that the plan of care leads to a better state of health not just modify it so the client achieves the outcomes. The other choices are appropriate to evaluate the plan of care.
question

Which action is appropriate when evaluating a client’s responses to a plan of care? Reinforce the plan of care when each expected outcome is achieved. Terminate the plan if there are difficulties achieving the goals/outcomes. Terminate the plan of care upon client discharge. Continue the plan of care if more time is needed to achieve the goals/outcomes.
answer

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.
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A nurse is following the rules recommended by the Institute of Medicine’s Committee on Quality of Health Care in America to help redesign and improve patient care. Which nursing actions are based on these rules? (Select all that apply.) The nurse bases patient care on established nursing needs and values. The nurse becomes the source of control for patient care. The nurse bases care on evidence-based decision making. The nurse customizes care based on availability of resources. The nurse promotes shared knowledge and the free flow of information. The nurse acknowledges that continuous decrease in waste improves patient care.
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-The nurse bases patient care on established nursing needs and values. -The nurse bases care on evidence-based decision making. -The nurse promotes shared knowledge and the free flow of information. -The nurse acknowledges that continuous decrease in waste improves patient care.
question

Priority setting is based on the information obtained during reassessment. Priority setting is used to rank nursing diagnoses. Each of the following contributes to priority setting except which of the following? Finances of the client The client’s condition Time and resources Feedback from the family
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Finances of the client Each of these factors contributes to the prioritization of nursing diagnoses except the client’s finances. The nursing code of ethics states that clients receive the same treatment regardless of their ability to pay.
question

Which scenario represents a nurse demonstrating the critical thinking process? assessing whether physician help is needed assessing why a physician encounter form is missing from the record collaborating with the respiratory therapist and physical therapist to address a complication using power for more control and freedom over the daily tasks
answer

assessing whether physician help is needed Critical thinking involves consistency, relevancy, and logical thinking. It enables the nurse to make decisions. Therefore, assessing whether physician help is needed is an example of the critical thinking process. The other actions support other nursing soft skills.

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