Test
Chapter 13: Outcome Identification & Planning
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Preguntas del test (35)
1A 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?
- AThe nurse formulates nursing diagnoses
- BThe nurse identifies expected patient outcomes
- CThe nurse selects evidence-based nursing interventions
- DThe nurse explains the nursing care plan to the patient
- EThe nurse assesses the patient's mental status
- FThe nurse evaluates the patient's outcome achievement
2 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?
- AA nurse sit down with a patient and prioritizes existing diagnoses
- BA nurse assesses a woman for postpartum depression during routine care
- CA nurse plans interventions for a patient who is diagnosed with epilepsy
- DA busy nurse takes time to speak to a patient who received bad news
- EA nurse reassesses a patient whose PRN pain medication is not working
- FA nurse coordinates the home care of a patient being discharged
3When 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?
- AInitial planning
- BStandardized planning
- COngoing planning
- DDischarge planning
4A 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. [blank_start]Ineffective Airway Clearance[blank_end]
2. [blank_start]Impaired Social Interaction[blank_end]
3. [blank_start]Disturbed Body Image[blank_end]
4. [blank_start]Spiritual Distress[blank_end]- AIneffective Airway Clearance
- BImpaired Social Interaction
- CDisturbed Body Image
- DSpiritual Distress
5A 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?
- AThe nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs
- BThe nurse uses a binary decision tree for stepwise assessment and interventions
- CThe nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes
- DThe nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice
- EThe nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research
- FThe nurse uses a decision tree that provides intense specificity and no provider flexibility
6A 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
- AWithin 1 day after teaching, the patient will list 3 benefits of continuing to apply moist compresses to leg ulcer after discharge
- BBy 6/12/15 the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer
- CBy 6/19/15 the patient's ulcer will begin to show signs of healing (e.g. size shrinks from 3" to 2.5")
- DBy 6/12/15, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer
7A 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:
- AAfter receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body
- BBy 8/15/15, patient will be able to use right arm to dress, comb hair, and feed herself
- CFollowing physical therapy, patient will begin to gradually participate in walking/running events
- DBy 8/15/15, patient will verbalize feeling sufficiently prepared to participate in running events
8A nurse is caring for an elderly male patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written?
- AOffer the patient 60 mL fluid every 2 hours while awake.
- BDuring the next 24 hour period, the patient's fluid intake will total at least 2,000 mL
- CTeach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/15
- DAt the next visit, 12/23/15, the patient will know that he should drink at least 3 liters of water per day
9A 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?
- AActual
- BPossible
- CRisk
- DCollaborative
10A 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?
- AOffer 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
- BTeach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on records at bedside
- CWalk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake
- DManage patient's pain
11You should first meet the needs that the patient thinks are most important, as long as this order does not interfere w/other vital therapies.
- AVerdadero
- BFalso
12For each nursing diagnosis at least one outcome should be written, that if achieved, demonstrates a direct resolution of the problem.
- AVerdadero
- BFalso
13to 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: [blank_start]the patient's fluid intake[blank_end]
verb: [blank_start]will total[blank_end]
performance criteria: [blank_start]2,000 mL[blank_end]
target time: [blank_start]during the next 24hr[blank_end]- Athe patient's fluid intake
- Bwill total
- C2,000 mL
- Dduring the next 24hr
14to be measurable, outcomes should have the following:
1. [blank_start]subject[blank_end]: the patient or some part of the patient
2. [blank_start]verb[blank_end]: indicates the action the patient will perform (i.e., define, prepare, verbalize, demonstrate, etc.)
3. [blank_start]conditions[blank_end]: specifies the particular circumstances in or by which the outcome is to be achieved (optional)
4. [blank_start]performance[blank_end] [blank_start]criteria[blank_end]: describe in observable, measurable terms the expected patient behavior or other manisfestation
5. [blank_start]target[blank_end] [blank_start]time[blank_end]: 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.)- Asubject
- Bverb
- Cconditions
- Dperformance
- Ecriteria
- Ftarget
- Gtime
15But whereas the [blank_start]problem[blank_end] [blank_start]statement[blank_end] of the diagnosis suggests the patient goals, it is the cause of the problem that suggest the [blank_start]nursing[blank_end] [blank_start]interventions[blank_end].
- Aproblem
- Bstatement
- Cnursing
- Dinterventions
16Structure Care Methodologies
[blank_start]Algorithm[blank_end]:
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
[blank_start]Clinical Pathway[blank_end]
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
[blank_start]Guideline[blank_end]
1. Broad, research based practice recommendations
2. May or may not have been tested in clinical practice
3. No mechanism for ensuring practice implementation
[blank_start]Order Set[blank_end]
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
[blank_start]Protocol[blank_end]
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- AAlgorithm
- BClinical Pathway
- CGuideline
- DOrder Set
- EProtocol
17A nurse is giving postoperative care to a client after knee arthroplasty. Which of the following is a possible short term goal for this client?
- Ato prevent surgery in the client
- Bto ambulate a client to a bed side chair
- Cto help a client return to ADLs
- Dto help maintain a healthy and active lifestyle
18The nursing student asks the nurse about nurse-initiated and physician-initiated nursing interventions. Which of the following is a nurse initiated nursing intervention?
- Aadminister a 1000 mL soap suds enema
- Badminister oxygen 4 L/min per nasal canula
- Cteach client how to splint abdominal incision when coughing and deep breathing
- Dadminister morphine sulfate 2mg IV push every 3 hours as needed for pain
19Which of the following are verbs that are helpful in writing measurable outcomes
- Aknow
- Bhear
- Cdefine
- Dverbalize
- Efeel
20Which of the following outcomes is sufficiently measurable?
- AClient will maintain adequate intake w/no complaints of nausea by 12/15/2011
- BIncrease client's diet from clear fluids to full fluids by 12/15/2011
- CClient will tolerate a full fluid diet with no complaints of nausea by 12/15/2011
- DClient will progress from clear fluid diet to full fluid diet w/out experiencing nausea
21A 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?
- AAn order set
- BGuidelines
- CAn algorithm
- DA standardized care plan
22Which of the following reflects outcome identification?
- AThe client demonstrates desire to achieve self administration of insulin
- BThe client identifies "3 or less" as the desired level of anxiety
- CThe nurse offers graham crackers at bedtime
- DThe nurse documents the client's response to IV antihypertensive medication
- EAbdomen soft and non-distended w/hyperactive bowel sounds
23Which one of the following is categorized as a psychomotor outcome?
- AThe client's skin will remain smooth, moist, and w/out breakdown and ulcerations
- Bw/in one week of attending class, the client will have cut smoking from 20 to 10 cigarettes a day
- Cthe client will verbalize understanding of need to continue to take medications as prescribed
- Dw/in 2 days of education the client's wife will demonstrate abdominal dressing change
24Which statement correctly describes a nurse-initiated intervention?
- Anurse-initiated interventions are actions performed to diagnose a medical problem
- Bnurse-initiated interventions are derived from the problem statement of the nursing diagnosise
- Cnurse-initiated interventions are derived from the nursing diagnosis
- Dnurse-initiated interventions require a physician's order
25although 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?
- Adischarge
- Binitial
- Cstandardized
- Dongoing
26What is true of nursing responsibilities with regards to a physician initiated intervention (physician's order)?
- ANurses are not legally responsible for these interventions
- BNurses do not carry them out
- CNurses are responsible for reminding physicians to implement orders
- DNurses do carry out interventions in response to a physician's orders
27A 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?
- AOnce she is admitted to the nursing unit from postanesthetic recovery
- BAs soon as possible after her surgery
- CUpon her admission to the hospital
- DOne she has received a discharge order
28When the nurse notices a client is in pain and needs to learn to walk on crutches, which outcome identification is the priority?
- Acapillary refill
- Bpain management
- Ccrutch walking
- Dsafe walking
29A 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?
- Arealistic
- Bcognitive
- Caffective
- Dpsychomotor
30When 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?
- AThe statement expresses a client outcome as a nursing intervention
- BThe outcome is not observable or measurable
- CThe outcome is not related to an independent nursing action
- DThe outcome doesn't specify the conditions in which it will be achieved
31The nurse recognizes that identifying outcomes/goals must include which of the following?
- AInput from the physician
- BInput from the multidisciplinary team
- CInvolvement of the client and family
- DInvolvement of the staff manager and other staff nurses
32Patient 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?
- Asubject
- Bperformance criteria
- Cverb
- Dtarget time
- Econdition
33Which of the following is a correctly written nursing intervention?
- AKnow the signs/symptoms of infection
- BReposition the client from side to side every hour around the clock
- CProvide 5 to 6 small meals daily
- DUnderstand the side effects of Lasix (furosemide)
- EProvide opportunities for the client to express concerns and verbalize feelings
34An 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?
- AThe client will ambulate 100 feet w/out supplementary oxygen or mobility aids
- BThe client will return home, able to conduct her ADLs w/out experiencing SOB
- CThe client will express an understanding of strategies for managing fatigue and SOB
- DThe client will demonstrate the correct use of her metered dose inhaler
35A 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?
- Adischarge
- Binitial
- Congoing
- Doutcome
Información
- Descripción
- UNIT III: Person-Centered Care and the Nursing Process Chapter 13: Outcome Identification & Planning
- Autor
- Alexandra Bozan
- Idioma
- English
- Visitas
- 210
- Etiquetas
- Valoración
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