Alexandra Bozan
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UNIT III: Person-Centered Care and the Nursing Process Chapter 13: Outcome Identification & Planning

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Alexandra Bozan
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Chapter 13: Outcome Identification & Planning

Question 1 of 35

1

A nurse is planning care for a male adolescent patient who is admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process?

Select one or more of the following:

  • The nurse formulates nursing diagnoses

  • The nurse identifies expected patient outcomes

  • The nurse selects evidence-based nursing interventions

  • The nurse explains the nursing care plan to the patient

  • The nurse assesses the patient's mental status

  • The nurse evaluates the patient's outcome achievement

Explanation

Question 2 of 35

1

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning?

Select one or more of the following:

  • A nurse sit down with a patient and prioritizes existing diagnoses

  • A nurse assesses a woman for postpartum depression during routine care

  • A nurse plans interventions for a patient who is diagnosed with epilepsy

  • A busy nurse takes time to speak to a patient who received bad news

  • A nurse reassesses a patient whose PRN pain medication is not working

  • A nurse coordinates the home care of a patient being discharged

Explanation

Question 3 of 35

1

When helping a patient turn in bed, the nurse notices that his heels are reduced and plans to place him on precautions for skin breakdown. This is an example of what type of planning?

Select one of the following:

  • Initial planning

  • Standardized planning

  • Ongoing planning

  • Discharge planning

Explanation

Question 4 of 35

1

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: List the problems in order of highest priority to lowest.

1.
2.
3.
4.

Drag and drop to complete the text.

    Ineffective Airway Clearance
    Impaired Social Interaction
    Disturbed Body Image
    Spiritual Distress

Explanation

Question 5 of 35

1

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care?

Select one or more of the following:

  • The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs

  • The nurse uses a binary decision tree for stepwise assessment and interventions

  • The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes

  • The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice

  • The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research

  • The nurse uses a decision tree that provides intense specificity and no provider flexibility

Explanation

Question 6 of 35

1

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An example of an affective outcome for this patient is

Select one of the following:

  • Within 1 day after teaching, the patient will list 3 benefits of continuing to apply moist compresses to leg ulcer after discharge

  • By 6/12/15 the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer

  • By 6/19/15 the patient's ulcer will begin to show signs of healing (e.g. size shrinks from 3" to 2.5")

  • By 6/12/15, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer

Explanation

Question 7 of 35

1

A nurse is preparing a clinical outcome for a 32-year-old female runner who is recovering from a stroke that caused right-sided paresis. An example of this type of outcome is:

Select one of the following:

  • After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body

  • By 8/15/15, patient will be able to use right arm to dress, comb hair, and feed herself

  • Following physical therapy, patient will begin to gradually participate in walking/running events

  • By 8/15/15, patient will verbalize feeling sufficiently prepared to participate in running events

Explanation

Question 8 of 35

1

A nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written?

Select one of the following:

  • Offer the patient 60 mL fluid every 2 hours while awake.

  • During the next 24 hour period, the patient's fluid intake will total at least 2,000 mL

  • Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/15

  • At the next visit, 12/23/15, the patient will know that he should drink at least 3 liters of water per day

Explanation

Question 9 of 35

1

A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68 year old male patient. What type of diagnosis does this intervention seek to confirm?

Select one of the following:

  • Actual

  • Possible

  • Risk

  • Collaborative

Explanation

Question 10 of 35

1

A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement below is not an example of a well-stated nursing intervention?

Select one of the following:

  • Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL

  • Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on records at bedside

  • Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake

  • Manage patient's pain

Explanation

Question 11 of 35

1

You should first meet the needs that the patient thinks are most important, as long as this order does not interfere w/other vital therapies.

Select one of the following:

  • True
  • False

Explanation

Question 12 of 35

1

For each nursing diagnosis at least one outcome should be written, that if achieved, demonstrates a direct resolution of the problem.

Select one of the following:

  • True
  • False

Explanation

Question 13 of 35

1

to be measurable, outcomes should have the following: subject, verb, conditions (optional), performance criteria, target time

During the next 24 hr period, the patient's fluid intake will total at least 2,000 mL
subject:
verb:
performance criteria:
target time:

Drag and drop to complete the text.

    the patient's fluid intake
    will total
    2,000 mL
    during the next 24hr

Explanation

Question 14 of 35

1

to be measurable, outcomes should have the following:

1. : the patient or some part of the patient

2. : indicates the action the patient will perform (i.e., define, prepare, verbalize, demonstrate, etc.)

3. : specifies the particular circumstances in or by which the outcome is to be achieved (optional)

4. : describe in observable, measurable terms the expected patient behavior or other manisfestation

5. : specifies when the patient is expected to be able to achieve the outcome. may be a realistic actual date or statement indicating time (i.e. before discharge, whenever observed, etc.)

Drag and drop to complete the text.

    subject
    verb
    conditions
    performance
    criteria
    target
    time

Explanation

Question 15 of 35

1

Fill the blank spaces to complete the text.

But whereas the of the diagnosis suggests the patient goals, it is the cause of the problem that suggest the .

Explanation

Question 16 of 35

1

Structure Care Methodologies

:
1. Binary decision trees that guide step wise assessment and intervention
2. Useful in management of high-risk subgroups w/in the cohort, may be layered on top of a pathway to control care practices that are used to manage a specific problem
3. Intense specificity, no provider flexibility
4. May use analytical research methods to ensure cause/effect


1. Represents a sequential, interdisciplinary, minimal practice standard for a specific patient population
2. Provides flexibility to alter care to meet individualized patient needs
3. Ability to measure cause/effect relationship between pathway and patient outcomes


1. Broad, research based practice recommendations
2. May or may not have been tested in clinical practice
3. No mechanism for ensuring practice implementation


1. Preprinted provider orders used to expedite the order process after a practice standard has been validated through analytical research
2. Compliments and increases compliance w/existing practice standards
3. Can be used to represent the algorithm or protocol in order format


1. Prescribes specific therapeutic interventions for a clinical problem unique to a subgroup of patients w/the cohort
2. Multifaceted; may be used to drive practice for more than one discipline
3. Broader specificity than an algorithm; allows for minimal provider flexibility by way of treatment option
4. May be layered on top of a pathway

Drag and drop to complete the text.

    Algorithm
    Clinical Pathway
    Guideline
    Order Set
    Protocol

Explanation

Question 17 of 35

1

A nurse is giving postoperative care to a client after knee arthroplasty. Which of the following is a possible short term goal for this client?

Select one of the following:

  • to prevent surgery in the client

  • to ambulate a client to a bed side chair

  • to help a client return to ADLs

  • to help maintain a healthy and active lifestyle

Explanation

Question 18 of 35

1

The nursing student asks the nurse about nurse-initiated and physician-initiated nursing interventions. Which of the following is a nurse initiated nursing intervention?

Select one of the following:

  • administer a 1000 mL soap suds enema

  • administer oxygen 4 L/min per nasal canula

  • teach client how to splint abdominal incision when coughing and deep breathing

  • administer morphine sulfate 2mg IV push every 3 hours as needed for pain

Explanation

Question 19 of 35

1

Which of the following are verbs that are helpful in writing measurable outcomes

Select one or more of the following:

  • know

  • hear

  • define

  • verbalize

  • feel

Explanation

Question 20 of 35

1

Which of the following outcomes is sufficiently measurable?

Select one of the following:

  • Client will maintain adequate intake w/no complaints of nausea by 12/15/2011

  • Increase client's diet from clear fluids to full fluids by 12/15/2011

  • Client will tolerate a full fluid diet with no complaints of nausea by 12/15/2011

  • Client will progress from clear fluid diet to full fluid diet w/out experiencing nausea

Explanation

Question 21 of 35

1

A nurse caring for a client admitted with a deep vein thrombosis is individualizing a prepared plan of care that identifies nursing diagnoses, outcomes, and related nursing interventions common to this condition. What type of tool is the nurse using?

Select one of the following:

  • An order set

  • Guidelines

  • An algorithm

  • A standardized care plan

Explanation

Question 22 of 35

1

Which of the following reflects outcome identification?

Select one or more of the following:

  • The client demonstrates desire to achieve self administration of insulin

  • The client identifies "3 or less" as the desired level of anxiety

  • The nurse offers graham crackers at bedtime

  • The nurse documents the client's response to IV antihypertensive medication

  • Abdomen soft and non-distended w/hyperactive bowel sounds

Explanation

Question 23 of 35

1

Which one of the following is categorized as a psychomotor outcome?

Select one of the following:

  • The client's skin will remain smooth, moist, and w/out breakdown and ulcerations

  • w/in one week of attending class, the client will have cut smoking from 20 to 10 cigarettes a day

  • the client will verbalize understanding of need to continue to take medications as prescribed

  • w/in 2 days of education the client's wife will demonstrate abdominal dressing change

Explanation

Question 24 of 35

1

Which statement correctly describes a nurse-initiated intervention?

Select one of the following:

  • nurse-initiated interventions are actions performed to diagnose a medical problem

  • nurse-initiated interventions are derived from the problem statement of the nursing diagnosise

  • nurse-initiated interventions are derived from the nursing diagnosis

  • nurse-initiated interventions require a physician's order

Explanation

Question 25 of 35

1

although each care plan is individualized, there are certain risks and health problems that clients undergoing similar medical or surgical treatment have in common. What name is given to this type of care plan?

Select one of the following:

  • discharge

  • initial

  • standardized

  • ongoing

Explanation

Question 26 of 35

1

What is true of nursing responsibilities with regards to a physician initiated intervention (physician's order)?

Select one of the following:

  • Nurses are not legally responsible for these interventions

  • Nurses do not carry them out

  • Nurses are responsible for reminding physicians to implement orders

  • Nurses do carry out interventions in response to a physician's orders

Explanation

Question 27 of 35

1

A client's diagnoses of breast cancer necesitates a bilateral mastectomy and breast reconstruction with tissue expanders. The nurse recognizes that the client's surgery will have a significant impact on her ADLs. When should discharge planning to address ADLs begin for this client?

Select one of the following:

  • Once she is admitted to the nursing unit from postanesthetic recovery

  • As soon as possible after her surgery

  • Upon her admission to the hospital

  • One she has received a discharge order

Explanation

Question 28 of 35

1

When the nurse notices a client is in pain and needs to learn to walk on crutches, which outcome identification is the priority?

Select one of the following:

  • capillary refill

  • pain management

  • crutch walking

  • safe walking

Explanation

Question 29 of 35

1

A nurse writes down the following outcome for a depressed client "By 6/9/12 the client will state 3 positive benefits of receiving counseling." This is an example of which of the following types of outcome?

Select one of the following:

  • realistic

  • cognitive

  • affective

  • psychomotor

Explanation

Question 30 of 35

1

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 9/9/15" Why is this outcome inadequate?

Select one of the following:

  • The statement expresses a client outcome as a nursing intervention

  • The outcome is not observable or measurable

  • The outcome is not related to an independent nursing action

  • The outcome doesn't specify the conditions in which it will be achieved

Explanation

Question 31 of 35

1

The nurse recognizes that identifying outcomes/goals must include which of the following?

Select one of the following:

  • Input from the physician

  • Input from the multidisciplinary team

  • Involvement of the client and family

  • Involvement of the staff manager and other staff nurses

Explanation

Question 32 of 35

1

Patient education in the care of a male patient with emphysema has focused on smoking cessation. As a result, nurses have prioritized the following outcome in his plan of care "By 1/12/2011, patient will state that he no longer smokes" This outcome contains which of the following components of a measurable outcome?

Select one or more of the following:

  • subject

  • performance criteria

  • verb

  • target time

  • condition

Explanation

Question 33 of 35

1

Which of the following is a correctly written nursing intervention?

Select one or more of the following:

  • Know the signs/symptoms of infection

  • Reposition the client from side to side every hour around the clock

  • Provide 5 to 6 small meals daily

  • Understand the side effects of Lasix (furosemide)

  • Provide opportunities for the client to express concerns and verbalize feelings

Explanation

Question 34 of 35

1

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

Select one of the following:

  • The client will ambulate 100 feet w/out supplementary oxygen or mobility aids

  • The client will return home, able to conduct her ADLs w/out experiencing SOB

  • The client will express an understanding of strategies for managing fatigue and SOB

  • The client will demonstrate the correct use of her metered dose inhaler

Explanation

Question 35 of 35

1

A client was admitted 2 days ago with sepsis. The nurse updates the client's care plan based upon improvements in his condition. This is an example of which type of planning?

Select one of the following:

  • discharge

  • initial

  • ongoing

  • outcome

Explanation

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