Deck 8: Outcome Identification and Planning

Question 1

Planning care in the outcome identification phase allows:

A) evaluation of nursing interventions.
B) promotion of client participation in care.
C) the diagnostic process to progress efficiently.
D) the identification of proper diagnoses.

Answer 1

promotion of client participation in care.

Question 2

A client is rehabilitating from a fractured right leg and is learning to walk on crutches. Together, the client and the nurse have established a plan for the client to walk with a three-point gait for 20 feet by the next day. In outcome identification, what is this termed?

A) Establishing a client goal
B) Evaluation of crutch training
C) Collaboration with physical therapy
D) Implementation of crutch walking

Answer 2

Establishing a client goal

Question 3

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

A) Crutch walking
B) Safe walking
C) Capillary refill
D) Pain management

Answer 3

Pain management

Question 4

A client is unconscious and unable to provide input into outcome identification. With which group of individuals should the nurse consult for the formulation of goals and measurable outcomes?

A) Family
B) Physical therapists
C) Occupational therapists
D) Pharmacists

Question 5

A nurse identifies outcomes of care for the hospitalized, postoperative client primarily to:

A) document nursing practice.
B) evaluate nursing interventions.
C) focus on health promotion.
D) provide individualized care.

Question 6

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

A) North American Nursing Diagnoses List
B) Nursing Outcome Classification
C) McCaffrey Pain Management Scale
D) Outcome Criteria Listing Source

Question 7

The Nursing-Sensitive Outcomes Classification system organizes outcomes by:

A) nursing diagnosis.
B) medical diagnosis.
C) critical pathway.
D) measurement activities.

Question 8

Which nursing diagnosis is high priority?

A) Spiritual distress
B) Stress incontinence
C) Anxiety
D) Ineffective breathing patterns

Question 9

For the postoperative client, which nursing diagnosis will require outcome identification that could contribute to a maladaptive postoperative recovery?

A) Pain
B) Ineffective breathing patterns
C) Alteration in bowel elimination
D) Anxiety

Question 10

What is the purpose of the client outcome?

A) To address the problem in the nursing diagnosis
B) To evaluate the plan of care developed
C) To provide a basis for the scientific rationale
D) To coordinate the nursing intervention

Question 11

When establishing client outcomes with the client, what is the qualifier in the outcome?

A) The short-term goal
B) The long-term goal
C) The problem statement
D) The outcome parameter

Question 12

What are specific, measurable, and realistic statements of goal attainment?

A) Nursing diagnoses
B) Nursing interventions
C) Evaluation
D) Outcome criteria

Question 13

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

A) physiologic
B) behavioral
C) coping
D) family

Question 14

A treatment based on a nurse's clinical judgment and knowledge to enhance client outcomes is a nursing:

A) diagnosis.
B) evaluation.
C) intervention.
D) goal.

Question 15

A nurse is demonstrating Foley catheter care to a client. Which type of nursing intervention does this best represent?

A) Surveillance
B) Maintenance
C) Supervisory
D) Educational

Question 16

When a nurse assists a postoperative client to the chair, which type of nursing intervention does this represent?

A) Maintenance
B) Surveillance
C) Psychomotor
D) Psychosocial

Question 17

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students. The primary difference is that the clinical nursing care plan usually:

A) does not contain documented scientific rationales.
B) does not contain abbreviated nursing diagnoses.
C) separates goal statements from the plan of care.
D) separates outcome criteria from the plan of care.

Question 18

One of the primary factors that the nurse considers when setting priorities for the client in the acute care setting after cardiac surgery is the client's:

A) support system.
B) medical orders.
C) past medical history.
D) condition.

Question 19

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?

A) Assessment
B) Diagnosis
C) Outcome identification and planning
D) Implementation

Question 20

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.

A) Demonstrate
B) Understand
C) State
D) Know
E) Explain

Question 21

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.

A) Can be measured
B) Are realistic
C) Are specific
D) Are focused short term
E) Must be broad in scope

Question 22

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):

A) nursing diagnosis.
B) outcome criteria.
C) intervention.
D) client outcome.

Question 23

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.

A) Definition
B) Measurement scale
C) Indicators
D) Time frames
E) Behaviors

Question 24

Which statement on a plan of care would a nurse identify as a nursing intervention?

A) Administers insulin correctly
B) Demonstrates deep-breathing exercises after education
C) Performs range-of-motion exercises to all joints each morning
D) Readiness for enhanced communication