Course Point – Chapter 13: Outcome Identification & Planning – Flashcards
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Outcome identification & Planning steps
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Nurse works in partnership with the patient and family to: establish priorities, identify and write expected patient outcomes, select evidence-based interventions, communicate the plan of nursing care.
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Goal
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an aim or an end.
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Patient outcome
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an expected conclusion to a patient health problem, or in the event of a wellness diagnosis, an expected conclusion to a patient's health expectation.
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Expected outcomes
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refers to more specific, measurable criteria used to evaluate the extent to which a goal has been met.
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Initial planning
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performed by the nurse with the admission nursing history and the physical assessment.
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Standardized care plans
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prepared plans of care that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem.
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Ongoing planning
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carried out by any nurse who interacts with the patient. Chief purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function.
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Discharge planning
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carried out by the nurse who has worked most closely with the patient and family, possible in conjunction with a nurse or social worker with a broad knowledge of existing community resources.
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Nursing Outcomes Classification (NOC)
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developed by the Iowa Outcomes Project presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention.
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Nursing intervention
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any treatment based upon clinical judgement and knowledge that an nurse performs to enhance patient/client outcomes.
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Nurse initiated intervention
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autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnoses and projected outcomes.
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Physician initiated intervention
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initiated by a physician in response to a medical diagnosis but is carried out by a nurse in response to a doctor's order. Nurse who performs these interventions is implementing physician initiated intervention. both the physician and nurse are legally responsible for these interventions, and nurses are expected to be knowledgeable about how to execute these interventions safely and effectively.
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collaborative interventions
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nurses that carry out treatments initiated by other providers such as pharmacists, respiratory therapists, or physician assistants.
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consultation
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a process in which two or more people with varying degrees of experience and expertise discuss a problem and its solution, often proves helpful.
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Plan of nursing care
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written guide that directs the efforts of the nursing team working with patients to meet their health goals.
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The nurse is writing goals for clients being discharged from an acute care setting. Which goals are written correctly? Select all that apply.
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• After attending an infant care class, the client will correctly demonstrate the procedure for bathing her newborn. • After counseling, the client will describe two coping measures to deal with stress. • By 4/5/15, the client will demonstrate how to care for a colostomy. Goals must be client-centered, specific, measurable, attainable, realistic, and timebound. The above goals that have these characteristics are: "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"; and "After counseling, the client will describe two coping measures to deal with stress." "Demonstrate the correct use of crutches to the client prior to discharge" is a nursing intervention. "The client will know how to dress her wound after receiving a demonstration" is not measurable. The client demonstrating a technique is measurable, but "will know" is not measurable. "The client will list the dangers of smoking and quit" is not timebound. (less)
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A 56-year-old woman on the inpatient unit is 2 hours s/p gallbladder surgery. She is just waking up from anesthesia, and asks the nurse how long it will take until she can go home. The nurse responds that most clients are discharged within 2 days. The nurse's answer is most likely based on which piece of information?
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The agency's critical path The critical path is based on large bodies of research and provides information on the expected course of a client's treatment or illness. Deviations from the critical path are documented in the individualized plan of care.
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A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?
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Client will have formed stools within 24 hours. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with diarrhea, the most direct resolution of diarrhea is for the stool consistency to return to normal. (less)
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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. Outcomes should be specific, measurable, attainable, realistic, and timebound. Demonstrating hand hygiene before and after port care 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." (less)
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A nurse is using the Nursing Outcome Classification system to assist in planning a client's care. The nurse understands that each outcome includes which component? Select all that apply.
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• Definition • Measurement scale • Indicators Each nursing-sensitive outcome has a definition, a measurement scale, and associated indicators and measures. Time frames and behaviors are not typical components.
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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. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for hypertension is to have the blood pressure return to the expected range of between 90/60 mmHg and 120/80 mmHg. The other options do not directly indicate successful control of hypertension. (less)
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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." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new diagnosis must learn appropriate actions for care. With osteoporosis the most important means to prevent further bone loss is weight-bearing activity, such as walking. While each option is appropriate for a client with osteoporosis, only one includes both components of the outcome. Activities that prevent falls, such as wearing low-heeled tie shoes, turning on lights, and removing scatter rugs, are important for safety. (less)
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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. During the planning step of the nursing process the nurse develops and prioritizes an individualized plan of care in partnership with the client, family, and others as appropriate. The client with mental or physical limitations should be included in the plan as much as possible. When there are cognitive limits, the client's power of attorney (POA) should also be included in the plans.
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The expected outcome for a client with a new diagnosis of rheumatoid arthritis (RA) 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 should call my health care provider if I have a sore that won't heal." The primary purpose of a client outcome in a plan of care is to evaluate the successful prevention, reduction, or resolution of client health problems and the attainment of the client's health expectations. A client learning about a new medication routine must learn appropriate actions of administration, storage, and conditions require contact with the health care provider. (less)
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A nurse is caring for a 30-year-old man status post repair of a left femur fracture. He is currently immobilized and on strict bed rest. The nurse enters the client's room every 2 hours to help him change positions because doing so will help to prevent pressure ulcers. The "help to prevent pressure ulcers" portion of this statement is best described as:
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rationale The nursing rationale is the "why." Students will often reference textbooks and journal articles to justify their actions in a care plan, and the rationale is termed "scientific rationale." (less)
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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 Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, or circulation. Safety issues, such as threats of self-harm, are also highest priority. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. In this case, the priority focus is diversional activity since the client must allow healing before walking and physical therapy can resume. While the other options are implied in the case, there is no direct evidence that they are higher priority than diversional activity. (less)
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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. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these actions will improve oral intake by the client with dysphagia, the most effective is a chin tuck and double swallow. These actions reduce the risk of aspiration and aid the movement of food down the esophagus. (less)
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A nurse is preparing an in-service program for a group of staff nurses who are returning to the workforce. As part of the in-service, the nurse will be describing the different types of client plans of care. Which element would the nurse include as common to any type of plan of care? Select all that apply.
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• Client goals • Nursing diagnoses • Nursing interventions The client plan of care can be written in various ways. Institutions may use a written or a computerized care plan design. Despite these design differences, the plan of care usually contains three key elements: the nursing diagnosis (client problem), client goals, and nursing interventions (nursing orders, nursing actions). (less)
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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 High-priority nursing diagnoses, such as Ineffective Airway Clearance, pose the greatest threat to the client's well-being and should be addressed by the nurse first.
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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. A specific, expected client outcome is written for each day in a collaborative plan of care. An expected client outcome after 24 hours of treatment for gouty arthritis is reduction in pain. Pain reduction may occur before reduction of redness and swelling is visible. Diarrhea is a possible toxic effect of colchicine. (less)
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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. The best long-term client outcome is to maintain nutritional intake without pain or diarrhea. The other outcomes are smaller increments that help the client reach the ultimate goal of controlling the disease. A formal plan of care allows the nurse to individualize care for maximal achievement of outcomes, set priorities, coordinate care, promote health care communication, and evaluate client response to care. (less)
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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. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. This client exhibited a possible complication of impaired peripheral tissue perfusion. The nurse modifies the plan of care to increase the frequency of assessment in order to identify further complication. While the other nursing interventions are routine comfort measures used following injury, they are not sufficient to treat the complication. (less)
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A nurse is reviewing the plan of care for a client and notes the following: "The client verbalizes three signs of hypoglycemia to the staff accurately before discharge." The nurse interprets this statement as a(n):
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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. Client outcome would be an educated guess made as a broad statement. (less)
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Which of the following reflects planning? Select all that apply.
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• The nurse decides to assist the client with ambulation in the hallway twice per shift. • The nurse seeks input from the client and family regarding acceptable non-pharmacologic pain management strategies. • The nurse considers the developmental level of the client when selecting education materials. The focus of outcome identification is to identify expected outcomes for a plan of care individualized to the client. Setting client goals, such as a tolerable anxiety level and self-administration of insulin, occurs in outcome identification. Assisting with bathing is an example of implementation. Assessment is considered separate from planning. Assisting the client is a form of implementation. (less)
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For which of the following clients would a standardized plan of care most likely be appropriate?
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a client who was admitted for shortness of breath and who has been diagnosed with pneumonia Standardized care plans are most appropriate for clients who are experiencing a common and specific health problem, such as pneumonia. Clients with multiple pathologies or symptoms of unknown etiology are unlikely to have their unique needs reflected in a standardized care plan. (less)
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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. Outcomes should be specific, measurable, attainable, realistic, and timebound. Expecting a transplant recipient to follow the medication schedule after surgery is reasonable and meets all the characteristics of an outcome. The other options are not complete. 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." (less)
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A preceptor reviews the client outcomes written by a new nurse. Which outcome is the highest priority for the client with paranoid delusions?
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Within 3 days, client will mingle in the day room without violence. Outcomes should be specific, measurable, attainable, realistic, and timebound. Words such as "know" and "understand" should be avoided because they are too general to be easily measured. Other common errors to avoid are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, and using verbs that are not observable. Safety is a priority for all clients. Clients with thought and mood disorders may present a risk of harm to self or others because of distorted thinking. Therefore, the ability of the client to mingle with others without violence is the highest priority. (less)
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A nurse is caring for a client who is on the medical unit status post pneumonia. The client has a medical order to "resume oral feeding as tolerated." Which are appropriate nursing interventions related to this medical order? Select all that apply.
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• Consult with dietitian regarding appropriate foods. • Begin feedings with clear broth. • Auscultate for bowel sounds. Feedings should begin slowly with clear liquids as the first food. Immediately resuming a standard diet after a period of n.p.o. is likely to result in GI distress.
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A nurse is working with a newly admitted client with diabetes to develop client outcomes. When writing these outcomes, which verb would be appropriate to use in the statement. Select all that apply.
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• Demonstrate • Explain • State When writing client outcomes it is important that an action verb is used so that the behavior can be evaluated. Verbs such as demonstrate, state, and explain are appropriate action verbs. Understand and know are difficult to evaluate because they lack a behavioral component. (less)
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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 Nursing intervention, nursing diagnosis, and client goals are important elements of a client's nursing care plan. Evaluation is not a key element of the written plan. Outcome criteria and client outcome are components of the client goal but not independent key elements of the plan of care. (less)
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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 Affective outcomes describe changes in client values, beliefs, and attitudes. Psychomotor outcomes describe the client's achievement of new skills. Cognitive outcomes describe increases in client knowledge or intellectual behaviors. Realistic is not a term used to define outcomes, even though outcomes should be realistic. (less)
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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 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". (less)
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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. A nursing intervention is any treatment based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes.
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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?
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The client will return home able to conduct her activities of daily living (ADLs) without experiencing shortness of breath. Resumption of ADLs in the home setting is characteristic of a long-term outcome. Explaining energy-conservation techniques, mobilizing in the hospital, and demonstrating correct medication administration are short-term outcomes that may be accomplished prior to discharge. (less)
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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 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. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates risk for self-harm, not resolution of the depression. The nurse will perform additional assessment and add the new nursing diagnosis to the care plan. Changing the care plan to incorporate this new data makes it the most effective for treating the client. Telling another nurse could assist in treatment, but is less formal and effective. (less)
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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 The cause of the patient health problem is referred to as the etiology. The problem statement of the nursing diagnosis suggests the patient goals, and the cause of the problem (etiology) suggests the nursing interventions. Identifying the unhealthy response preventing desired change would occur during the evaluation phase of the nursing process. Patient strengths are identified during the nursing diagnosis phase. (less)
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A 5-year-old client was recently diagnosed with type 1 diabetes. The nurse is in charge of her discharge education plan. The nurse knows that site rotation is important for long-term self-care. The statement "will properly identify three areas on her body to inject insulin" represents:
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outcome criteria. Outcome criteria are specific, measurable, realistic statements that can be evaluated to judge goal attainment.
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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 throughout the day. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will promote health in a client with COPD, the most direct resolution of activity intolerance is for the client to pace activities by alternating rest with exercise throughout the day. (less)
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A nurse is planning care for a client 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 client education. During the planning phase of the nursing process the nurse establishes priorities, identifies and writes expected client outcomes, selects evidence-based nursing interventions, and communicates the plan of nursing care. The nurse interprets and analyzes the data, and identifies client strengths and weaknesses during the diagnosis phase of the nursing process. Establishment of a database occurs during the assessment phase. (less)
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A nurse is applying the nursing process and is involved in establishing priorities. The nurse is most likely in which phase of the nursing process?
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Outcome identification and planning During outcome identification and planning, the nurse establishes priorities as well as client goals and outcome criteria for outcome identification. During this phase, the nurse also plans nursing interventions and writes the plan of care. Assessment involves data collection; diagnosis involves identifying client problems. Implementation involves putting the plan of care into action. (less)
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What are specific measurable and realistic statements of goal attainment?
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outcome criteria Outcome criteria are specific, measurable, realistic statements of goal attainment.
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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?
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Assess tracheostomy for patency. Airway impairment is considered a life-threatening emergency. This must be assessed and resolved before proceeding with other tasks.
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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:
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the problem statement of the nursing diagnosis. Outcomes are derived from the problem statement of the nursing diagnosis. Remember that the nursing process is based upon independent nursing actions.
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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 According to Maslow's Hierarchy of Needs, physiologic needs are essential to maintain life. These needs include oxygen, water, food, temperature, elimination, sexuality, physical activity, and rest. Cutting up food and opening drink containers for the client would meet the most basic need for food. The nurse is meeting safety needs by providing a mother with the phone number for the Poison Control Center. The nurse seeking input from the client regarding their preferences for a snack is showing respect to the individual and meeting self-esteem needs. When assisting the client to validate their feelings regarding treatment options, the nurse is acknowledging the uniqueness of the client and respects the client's knowledge and feelings in solving problems to attain self-actualization. (less)
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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 Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, circulation, or safety issues such as threats of self-harm. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. Lack of surfactant interferes with lung expansion and can reduce oxygenation in premature infants. Breastfeeding and temperature regulation are of lower importance than oxygenation. Parenting skills may be promoted when parents visit high-risk infants in the nursery. (less)
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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. Nurse-initiated interventions are derived from the nursing diagnosis and do not require a physician's order. Nurse-initiated interventions, like client goals, are derived from the nursing diagnosis. But whereas the problem statement of the diagnosis suggests the client goals, it is the cause of the problem (etiology) that suggests the nursing interventions. Nurse-initiated interventions do not necessarily pose a low risk of harm to the client. (less)
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A nurse administers clonidine 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 A specific, expected client outcome is written for each day in a collaborative plan of care. Expected client outcomes after 24 hours of treatment for hypertension would be for the blood pressure to be reduced toward the normal range, absence of headache, and no orthostatic hypotensive symptoms. However, a side effect of clonidine is weight gain and fluid retention that would require nursing intervention. (less)
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Which of the following is categorized as a psychomotor outcome?
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Within 2 days of education, the client's wife will demonstrate abdominal dressing change. Outcomes may be categorized according to the type of change they describe for the client. Psychomotor outcomes describe the client's achievement of new skills. Cognitive outcomes describe an increase in the client's knowledge. Affective outcomes describe changes in client values, beliefs, and standards. (less)
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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. An observation of a reddened area on a client's skin that doesn't blanch after pressure is relieved is characteristic of a first-degree pressure ulcer and indicates that the current nursing intervention of turning and repositioning the client every two hours to prevent impaired skin integrity is inadequate. The client's nursing care plan needs to be revised in order to reflect the new assessment finding of an actual pressure ulcer. Additionally, new nursing interventions need to be implemented to turn and reposition the client hourly in order to relieve the pressure on the trochanter ulcer and prevent the formation of new pressure ulcers. Repositioning the client to her back, documenting the intervention, reassessing the client's right trochanter in two hours, and documenting the condition of the skin in the medical record all fail to update the nursing care plan and revise the interventions to a more frequent turning and repositioning schedule. (less)
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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. The nursing interventions written to assist a client to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what assessments need to be made, what nursing interventions, including teaching, counseling, and advocacy, need to be done. There should also be further assessment of the outcome of the instruction. (less)
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The nursing student asks the nurse for guidance in selecting nursing interventions for the client's plan of care. Which response by the nurse would be inappropriate?
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"Nursing interventions are pretty much the same for clients that have the same medical diagnosis." Nursing interventions should be based on the etiology in the nursing diagnosis, be compatible with other planned therapies, be consistent with standards of care and research, and individualized for the client. (less)
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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?
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updating the diet orders in the client's plan of care The plan of care communicates three different types of nursing care related to meeting basic human needs, nursing diagnoses, and coordinating with medical and interdisciplinary care. Nutrition is a basic human need. The temporary need to withhold food and fluid should be documented in the record. The other options are not the best, most direct methods for conveying this information to all who may need it. (less)
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Which nursing diagnosis is high priority?
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Ineffective breathing patterns High-priority nursing diagnoses are those that are potentially life-threatening and require immediate action.
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According to the Nursing Intervention Classification (NIC), the most basic level of nursing intervention is:
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Physiologic The most basic domain of the seven domains of Nursing Intervention Classifications is Physiologic: Basic.
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A client stops in the hall after walking 30 feet and tells the nurse, "I don't want to do any more 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. While all of these interventions could be used to meet the client's outcomes, the most immediate need is for pain relief. Highest priority nursing diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, or circulation. Safety issues, such as threats of self-harm, are also highest priority. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences such as physical or emotional impairment. The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. This client has a medium level diagnosis because acute pain is interfering with function. (less)
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Which action is included in the planning process when a nurse is caring for an older adult client with AIDS?
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Identify measurable goals or outcomes. In the planning process, the nurse identifies measurable goals or outcomes, prioritizes nursing diagnoses and collaborative problems, selects appropriate interventions and documents the plan of care. The nurse assesses the client's overall health during the assessment step of the nursing process, not during the planning step. The nurse identifies the client's health-related problems during diagnosis and analyzes the client's response to medicines during the evaluation process. (less)
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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. Ongoing planning helps to resolve health problems and promote function. The nurse uses new data to make the plan more specific and effective. For this client, assessment indicates possible postoperative atelectasis. Changing the care plan to promote lung expansion is the most direct and effective method to resolve this problem. Reassessment is needed, but this does not replace the need for interventions. (less)
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A nurse is using the SMART acronym to plan outcomes for clients 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 S - specific; M - measurable; A - attainable; R - realistic; T - timebound.
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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. A clinical pathway communicates the standardized, interdisciplinary plan of care for a client. Care guidelines and outcomes are specified for each day of the client's hospital stay. An algorithm is a binary decision tree that guides stepwise assessment and intervention for a high-risk subgroup of clients. An order set is a preprinted set of provider orders that expedite the provider order process. A protocol prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of clients within the cohort. It has a broader specificity than an algorithm and allows for minimal provider flexibility by way of treatment options. (less)
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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 Nursing interventions are nurse-centered, action-oriented, and describe specifically what the nurse is doing (how, when, where, how often, how long, or how much). Providing 5 to 6 small meals, repositioning the client, and providing opportunities for expression of concerns and feelings are correctly written interventions. "Understand" and "know" are vague and are not action-oriented; it is unclear who is to perform these actions. Medication side effects and signs/symptoms of infection represent content that the nurse should know and teach to clients. (less)
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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. Nursing interventions designed to promote client independence will implement methods for the client to perform a skill without help. Assistive devices for eating, bathing, dressing, and ambulation are common tools to develop client independence. The other options do not directly promote independent activity. (less)
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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 Nursing diagnoses can be ranked for prioritization of care. Highest priority diagnoses are those that are the greatest threat to well-being and include situations that would compromise airway, breathing, or circulation; or safety issues such as threats of self-harm. Medium priority is given to client needs that are not life-threatening, but could cause unhealthy consequences (such as physical or emotional impairment). The lowest priority nursing diagnoses are those that require minimal intervention and cause minimal dysfunction. In this case, the lack of impulse control is the greatest risk to the client's well-being. (less)
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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. Outcomes should be specific, measurable, attainable, realistic, and timebound. Words such as "know" and "understand" should be avoided because they are too general to be easily measured. Other common errors to avoid are writing the outcome as a nursing intervention, including more than one client behavior in a short-term outcome, and using verbs that are not observable. (less)
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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. Client outcomes are derived from the problem statement of the nursing diagnosis. At least one outcome should be written so that it demonstrates a direct resolution of the problem statement. While each of these options will assist a client with dementia, the most direct resolution of wandering is for the client to remain in the presence of someone who can prevent wandering. (less)
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A client is on the surgical unit s/p resection of an intestinal tumor. She is alert and oriented x3. Based on assessment of the client, a medical order to "ambulate with assistance" is written in the chart. This will be the client's first time ambulating. Which best represents a nursing outcome?
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The client will ambulate with the assistance of a walker without falling within the next 4 hours.
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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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• Verbalize • Define The verb should indicate the action that is to be performed. Examples include define, prepare, identify, design, list, verbalize, describe, choose, explain, select, apply, and demonstrate. (less)
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A nurse is giving postoperative care to a client after knee arthroplasty. What is a possible short-term goal for this client?
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to ambulate the client to a bedside chair The short-term goal in this case is to help the client ambulate to the bedside chair. The other goals, like helping the client return to activities of daily life, to maintain a healthy and active lifestyle, and to prevent repeat surgery are long-term goals and may take weeks or months to achieve. On the other hand, short-term goals can be achieved in a day or a week. (less)
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The nurse is developing a plan of care for a newly admitted client to the nursing unit. The nurse knows that which elements are important to include in this plan of care? Select all that apply.
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• planning care that is realistic and measurable • promoting client participation • allowing for involvement of support people The goal of outcome identification is to provide individualized care, not standardized care.
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A 35-year-old construction worker fractured his right clavicle on the job. He is on the rehabilitation unit working to regain full function of his right arm. Which represents the best documentation of the evaluation of this client?
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Actively abducts right arm from 0 to 90 degrees, passive ROM from 90 to 180 degrees. Documentation should be specific. The evaluation is a form of communication with the multidisciplinary health care team.
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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. Which 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 Common problems with planning nursing care include failure to involve the client in the planning process, insufficient data collection, use of broadly stated outcomes, stating nursing orders that do not resolve the problem, and failure to update the plan of care. In this case, ALS is a progressive degenerative neuromuscular disorder. It is unrealistic to expect the client to regain abilities that are lost. (less)
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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. The focus of planning for a client who is expected to make a full recovery is promotion and restoration of health, alleviation of suffering, and prevention of illness, injury, and disease. A client recovering from surgery needs adequate pain control, sufficient nutritional intake for healing, and education in self-care if there are special needs, such as treating a wound, caring for a port, or administering medications. The oxygen saturation level is too low. The influenza vaccine should not be administered to someone with a moderate to severe acute illness. (less)
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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. The verb in this outcome "know" is not directly measurable or observable. The verb "demonstrate" would be more appropriate. Educating a client on how to use his or her nebulizer is an independent nursing action. The outcome is not expressed as a nursing intervention and conditions are not likely necessary for this outcome. (less)
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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. A nurse-initiated intervention is an autonomous action based on scientific rationale, which a nurse executes to benefit the client in a predictable way (related to the nursing diagnosis and expected outcomes). Nursing-initiated interventions, such as teaching, do not require a physician's order. A physician's order is required for the nurse to administer drugs (morphine sulfate and oxygen) and enemas. (less)
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The nurse assigned to care for a client has established client outcomes and outcome criteria. After completing this task, what would the nurse do next?
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Write a client plan of care The planning phase involves writing a client's plan of care based on the outcomes identified during outcome identification. Goals, objectives, and outcomes are terms often used interchangeably because they are statements of expectations. As such, they would be established during outcome identification, after priorities have been identified. (less)
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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 reports of nausea by 12/15/2016." A fully measurable outcome should include a subject, verb, conditions, performance criteria, and target time (though not every outcome requires each parameter). The outcome "Client will progress from clear fluid diet to full fluid diet without experiencing nausea" lacks a target time. The outcome "Increase client's diet from clear fluids to full fluids by 12/15/2016" expresses the outcome as a nursing intervention. The outcome "Client will maintain adequate intake with no reports of nausea by 12/15/2016" does not define the performance criteria sufficiently, since "adequate intake" is an imprecise term. (less)
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Which statement on a plan of care would a nurse identify as a nursing intervention?
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performs range of motion exercises to all joints each morning A nursing intervention is a treatment performed to enhance client outcomes, such as "performs range of motion exercises to all joints each morning." "Administers insulin correctly is a goal statement. "Demonstrates deep-breathing exercises after education" is a client outcome criteria. Readiness for enhanced communication is a wellness nursing diagnosis. (less)
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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.
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• are specific • are realistic • can be measured Outcome criteria are specific, measurable, realistic statements of goal attainment. They may restate the goal, but they also present information that will guide the evaluation phase of the nursing process. To be specific and measurable, certain requirements must be met when writing outcome criteria. Outcome criteria answer the questions who, what actions, under what circumstances, how well, and when. Outcomes may be short- or long-term and are broad statements about what the client's condition will be after nursing intervention. (less)
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A nurse is planning care for a client 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 client education. During the planning phase of the nursing process the nurse establishes priorities, identifies and writes expected client outcomes, selects evidence-based nursing interventions, and communicates the plan of nursing care. The nurse interprets and analyzes the data, and identifies client strengths and weaknesses during the diagnosis phase of the nursing process. Establishment of a database occurs during the assessment phase. (less)
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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. A guideline is defined as a broad, research-based practice recommendation that may or may not have been tested in clinical practice. An algorithm has intense specificity and provides no provider flexibility and is used to manage high-risk groups within a cohort. A critical pathway represents a minimal practice standard for a specific patient population. An order set includes preprinted provider orders used to expedite the order process. (less)
