Deck 13: Outcome Identification and Planning

Question 1

The nurse is planning the care of a male client who is receiving treatment for acute renal failure and who has begun dialysis three times weekly. The nurse has identified the following outcome: "Client will demonstrate the appropriate care of his arteriovenous fistula." This outcome is classified as which of the following?

A) Psychomotor
B) Affective
C) Cognitive
D) Holistic

Answer 1

Psychomotor

Question 2

A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?

A) Continue to follow the written plan of care.
B) Make recommendations for revising the plan of care.
C) Ask another health care professional to design a plan of care.
D) State "goal will be met at a later date."

Answer 2

Make recommendations for revising the plan of care.

Question 3

A nurse is discharging a client from the hospital. When should discharge planning be initiated?

A) At the time of discharge from an acute health care setting
B) At the time of admission to an acute health care setting
C) Before admission to an acute health care setting
D) When the client is at home after acute care

Answer 3

At the time of admission to an acute health care setting

Question 4

What name is given to tools that are used to communicate a standardized interdisciplinary plan of care for clients within a case management health care delivery system?

A) Kardex care plans
B) Computerized plans of care
C) Clinical pathways
D) Student care plans

Question 5

Increasingly, health care institutions are implementing computerized plans of nursing care. A benefit of using computerized plans includes which of the following?

A) Reduction in the time spent on care planning
B) Increased autonomy related to the nursing care planning process
C) Enhanced individualization of a care plan
D) Increased nursing expertise in care planning

Question 6

A male client is scheduled to be fitted with a prosthesis following the loss of his nondominant hand in a farm accident several weeks earlier. Nurses have documented the following outcome during this stage of his care: "After attending an educational session, client will demonstrate correct technique for applying his prosthesis." Which of this client's following statements would signal a need to amend this outcome?

A) "I'm not interested one bit in wearing an artificial hand."
B) "I'm worried that I'm going to get some really strange looks when I wear this thing."
C) "I don't have a clue how this thing goes on and comes off."
D) "I don't understand the technology that's used in this artificial hand."

Question 7

Nurses make common errors in the identification and development of outcomes. Which of the following is a common error made when writing client outcomes?

A) The nurse expresses the client outcome as a nursing intervention.
B) The nurse develops measurable outcomes using verbs that are observable.
C) The nurse develops a target time when the client is expected to achieve that outcome.
D) The outcome should include a subject, verb, conditions, performance criteria, and target time.

Question 8

A resident of a long-term care facility refuses to eat until she has had her hair combed and her make-up applied. In this case, what client need should have priority?

A) The need to have nutrition
B) The need to feel good about oneself
C) The need to live in a safe environment
D) The need for love from others

Question 9

What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?

A) Problem statement
B) Defining characteristics
C) Etiology of the problem
D) Outcomes criteria

Question 10

Which of the following groups of terms best describes a nurse-initiated intervention?

A) Dependent, physician-ordered, recovery
B) Autonomous, clinical judgment, client outcomes
C) Medical diagnosis, medication administration
D) Other health care providers, skill acquisition

Question 11

Which of the following outcomes is correctly written?

A) Abdominal incision will show no signs of infection.
B) On discharge, client will be free of infection.
C) On discharge, client will be able to list five symptoms of infection.
D) During home care, nurse will not observe symptoms of infection.

Question 12

Critical thinking is an essential component in all phases of the nursing process. What question might be used to facilitate critical thinking during outcome identification and planning?

A) "How do I best cluster these data and cues to identify problems?"
B) "What problems require my immediate attention or that of the team?"
C) "What major defining characteristics are present for a nursing diagnosis?"
D) "How do I document care accurately and legally?"

Question 13

A nurse is developing outcomes for a specific problem statement. What is one of the most important considerations the nurse should have?

A) The written outcomes are designed to meet nursing goals
B) To encourage the client and family to be involved
C) To discourage additions by other healthcare providers
D) Why the nurse believes the outcome is important

Question 14

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow's hierarchy of basic human needs, is appropriate for what level of needs?

A) Physiologic
B) Safety
C) Love and belonging
D) Self-actualization

Question 15

What is the primary purpose of the outcome identification and planning step of the nursing process?

A) To collect and analyze data to establish a database
B) To interpret and analyze data so as to identify health problems
C) To write appropriate client-centered nursing diagnoses
D) To design a plan of care for and with the client

Question 16

The nurse is caring for a client who has been newly diagnosed with diabetes. One of the outcomes the nurse read on the client's plan of care this morning was: "Client will demonstrate correct technique for self-injecting insulin." The client required insulin prior to his lunch and successfully drew up and administered his insulin while the nurse observed. How should the nurse follow up this observation?

A) Record an evaluative statement in the client's plan of care.
B) Remove the outcome from the client's care plan.
C) Ask the nurse who wrote the plan of care to document this development.
D) Reassess the client's psychomotor skills at dinner time.

Question 17

The nurse develops long-term and short-term outcomes for a client admitted with asthma. Which of the following is an example of a long-term goal?

A) Client returns home verbalizing an understanding of contributing factors, medications, and signs and symptoms of an asthma attack.
B) By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the symptoms of asthma.
C) Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased.
D) Within 72 hours of admission, the client's respiratory rate returns to normal and retractions disappear.

Question 18

Which of the following illustrates a common error when writing client outcomes?

A) Client will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m.
B) Client will demonstrate correct sequence of exercises by next office visit.
C) Client will be less anxious and fearful before and after surgery.
D) On discharge, client will list five symptoms of infection to report.

Question 19

Which of the following types of care plans is most likely to enable the nurse to take a holistic view of the client's situation?

A) Kardex
B) Case management
C) Critical pathways
D) Concept map care plan

Question 20

During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived?

A) The defining characteristics
B) The related factors
C) The problem statement
D) The database

Question 21

Which intervention does the nurse recognize as a collaborative intervention?

A) Teach the client how to walk with a three-point crutch gait.
B) Administer spironolactone (Aldactone).
C) Perform tracheostomy care every eight hours.
D) Straight catheterize every six hours.

Question 22

Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards? Select all that apply.

A) Professional physicians' organizations
B) State Nurse Practice Acts
C) The Joint Commission
D) The Agency for Health Care Research and Quality
E) The Patient Health Partnership

Question 23

In which of the following clients has the order of priorities for nursing diagnoses changed? Select all that apply.

A) A client in a long-term care facility who had a stroke
B) A client who is recovering from a broken leg
C) A client who insists on using the bathroom instead of a bedpan
D) A client who appears confused after taking pain medication
E) A pregnant client whose contractions are progressing as anticipated

Question 24

Which of the following client outcomes best describes the parameters for achieving the outcome?

A) The client will eat a well-balanced diet.
B) The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow.
C) The client will cleanse his wound with soap and water and apply a dry sterile dressing.
D) The client will be without pain in 24 hours.

Question 25

What common problem is related to outcome identification and planning?

A) Failing to involve the client in the planning process
B) Collecting sufficient data to establish a database
C) Stating specific and measurable outcomes based on nursing diagnoses
D) Writing nursing orders that are clear and resolve the problem

Question 26

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client's priorities for care using which of the following?

A) Assessment skills
B) Nursing books
C) Client's records
D) Supervisor's advice

Question 27

A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the client states, "I am very nervous and scared to have surgery." What client outcome is the priority?

A) Evaluate the need for antibiotics.
B) Resolve the client's anxiety.
C) Provide preoperative education.
D) Prepare the client for surgery.

Question 28

Which of the following statements accurately describes the impact on nursing of using NIC/NOC standardized languages? Select all that apply.

A) They demonstrate the impact that nurses have on the system of health care delivery.
B) They standardize and define the knowledge base for nursing curricula and practice.
C) They limit the number of appropriate nursing interventions to be selected.
D) They hinder the teaching of clinical decision making to novice nurses.
E) They enable researchers to examine the effectiveness and cost of nursing care.

Question 29

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

A) Teach client how to transfer from bed to chair and chair to bed.
B) Administer oxygen 4 L/min per nasal cannula.
C) Assist the client with coughing and deep breathing every hour.
D) Monitor intake and output every 2 hours.

Question 30

Which of the following is an example of a well-stated nursing intervention?

A) Client will drink 100 mL of water every 2 hours while awake.
B) Offer client 100 mL of water every 2 hours while awake.
C) Offer client water when he complains of thirst.
D) Client will continue to increase oral intake when awake.

Question 31

Which of the following is a correctly written client goal?

A) The client will eliminate a soft formed stool.
B) The client understands what foods are low in sodium.
C) The client will ambulate 10 feet with a walker by October 12.
D) The client correctly self-administers the morning dose of insulin.

Question 32

The nurse formulates the following client outcome: Client will correctly draw up morning dose of insulin and identify four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made?

A) Expressed the client outcomes as a nursing intervention
B) Wrote vague outcomes that will confuse other nurses
C) Included more than one client behavior in the outcome
D) Used verbs that are not observable and measurable

Question 33

Which of the following is not appropriate in writing client-centered measurable outcomes?

A) The client or a part of the client
B) A flexible time frame
C) Observable, measurable terms
D) The action the client will perform

Question 34

While developing the plan of care for a new client on the unit the nurse must identify expected outcomes that are appropriate for the new client. What is a resource for identifying these appropriate outcomes?

A) Community Specific Outcomes Classification (CSO)
B) The Nursing-Sensitive Outcomes Classification (NOC)
C) State Specific Nursing Outcomes Classification (SSNOC)
D) Department of Health and Human Resources Outcomes Classification (HHROC)

Question 35

Which of the following is a correctly written client goal? Select all that apply.

A) The client will identify five low-sodium foods by October 9.
B) The client will know the signs and symptoms of infection.
C) The client will rate pain as a 3 or less on a 10-point scale by 5 pm today.
D) The client will understand the side effects of digoxin (Lanoxin).
E) The client will eat at least 75% of all meals by May 5.