Nursing Process: Planning Outcomes

Identify the choice that best completes the statement or answers the question.

____ 1. For which patient would it be most important to perform a comprehensive discharge plan?

1)
A teenager who is a first-time mother, single, and lives with her parents
2)
An older adult who has had a stroke affecting the left side of his body and lives alone
3)
A middle-aged man who has had outpatient surgery on his knee and requires crutches
4)
A young woman who was admitted to the hospital for observation following an accident

____ 2. The nurse is beginning discharge planning for an older adult with left-side weakness. All of the following are important, but which action is most important in ensuring that the discharge plan is successful?

1)
Start planning at admission
2)
Involve the family members
3)
Get patient input when making the plan
4)
Involve the multidisciplinary team

____ 3. What do initial, ongoing, and discharge planning have in common?

1)
They are based on assessment and diagnosis.
2)
They focus on the patient’s perception of his needs.
3)
They require input from a multidisciplinary team.
4)
They have specific timelines in which to be completed.

____ 4. Which client has the greatest need for comprehensive discharge planning?

1)
A woman who has just given birth to her second child and lives with her husband and 18-month-old daughter
2)
A man who has been readmitted for exacerbation of his chronic obstructive pulmonary disease
3)
A 12-year-old boy who had outpatient surgery on his knee and lives with his mother
4)
A woman who was just diagnosed with renal failure and has started peritoneal dialysis

____ 5. Which of the following is a benefit of standardized care plans, as defined in your text? Standardized care plans:

1)
Apply to every patient on a particular unit.
2)
Include both medical and nursing orders.
3)
Specify patient outcomes for each day.
4)
Help ensure that important interventions are not overlooked.

____ 6. How are standardized (model) care plans similar to unit standards of care? Standardized (model) care plans:

1)
Describe the care needed by patients in defined situations.
2)
Include specific goals and nursing orders.
3)
Become a part of the patient’s comprehensive care plan.
4)
Usually describe ideal nursing care.

____ 7. The nurse is planning care for a patient. She is using a standardized care plan for Impaired Walking related to left-side weakness. Which of the following activities will the nurse perform when individualizing the plan for the patient?

1)
Validating conflicting data with the patient
2)
Transcribing medical orders
3)
Stating the frequency for ambulation
4)
Performing a comprehensive assessment

____ 8. Which of the following is the best example of an outcome statement? The patient will:

1)
Use the incentive spirometer when awake.
2)
Walk two times during day and evening shift.
3)
Maintain an oxygen saturation above 92% while performing ADLs each morning.
4)
Tolerate 10 sets of range-of-motion exercises with physical therapy.

____ 9. How are critical pathways and standardized nursing care plans similar? Both:

1)
Specify daily, or even hourly, outcomes and interventions.
2)
Prescribe minimal care needed to meet recommended lengths of stay.
3)
Describe care common to all patients with a certain condition or situation.
4)
Emphasize medical problems and interventions.

____ 10. How is NOC different from the Omaha System?

1)
NOC can be used to write health restoration outcomes.
2)
NOC can be used in all specialty and practice areas.
3)
NOC can be used for individuals, families, or groups.
4)
NOC formulates goals based on nursing diagnoses.

____ 11. How are short-term goals different from long-term goals? Short-term goals:

1)
Can be met within a few hours or a few days.
2)
Are developed from the problem side of the nursing diagnosis.
3)
Must have target times/dates.
4)
Specify desired client responses to interventions.

____ 12. What do standardized nursing care plans and individualized care plans have in common? They both:

1)
Reflect critical thinking for a specific patient
2)
Are preprinted to apply to needs common to a group of patients
3)
Address a patient’s individual needs
4)
Provide detailed nursing interventions

____ 13. The nurse is individualizing Mr. Wu’s plan of care by writing a plan for his nursing diagnosis of Anxiety. Why does the nurse need to write goals/outcomes on the plan of care? Because outcomes describe:

1)
Desirable changes in the patient’s health status.
2)
Specific patient responses to medical interventions.
3)
Specific nursing behaviors to improve a patient’s health.
4)
Criteria to evaluate the appropriateness of a nursing diagnosis.

____ 14. Which of the following outcome statements contains the best example of performance criteria? The patient will:

1)
Turn herself in bed frequently while awake.
2)
Understand how to use crutches by Day 2.
3)
State that pain is decreased after being medicated.
4)
Eat 75% of each meal without complaint of nausea.

____ 15. Which of the following is true for goals/outcomes for collaborative problems?

1)
They are monitored only by other disciplines.
2)
They are usually sensitive to nursing interventions.
3)
They state that a complication will not occur.
4)
They state only broad performance criteria.

____ 16. How are NANDA problem labels and NOC outcome labels alike? Both describe:

1)
Health status in terms of human responses.
2)
Patient response before interventions are done.
3)
Patient response in positive terms.
4)
A pattern of related cues.

____ 17. The nursing diagnosis is: Impaired Memory related to fluid and electrolyte imbalances A.M.B. inability to recall recent events. Which of the following goals/outcomes must be included on the care plan?

1)
Checks current medications for mind-altering side effects
2)
Demonstrates use of techniques to help with memory loss
3)
Drinks at least 1500 cc of fluid per day
4)
Takes electrolyte supplements with meals

____ 18. A client arrives in the emergency department, pale and breathing rapidly. He immediately becomes unconscious and collapses to the floor. The nurse rapidly assesses the patient and decides the first series of actions that are called for. This scenario demonstrates:

1)
Formal planning.
2)
Informal planning.
3)
Ongoing planning.
4)
Initial planning.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. A nurse is caring for an 80-year-old patient of Chinese heritage. When planning outcomes for this patient, which actions by the nurse would meet the American Nurses Association standards for outcomes identification? Choose all that apply.

1)
Developing culturally appropriate outcomes
2)
Using the outcomes preprinted on the clinical pathway
3)
Choosing the best outcome for the patient, regardless of the costs involved in bringing it about
4)
Involving the patient and family in formulating the outcomes

Chapter 5. Nursing Process: Planning Outcomes

Answer Section

MULTIPLE CHOICE

1. ANS: 2

A comprehensive discharge plan should be developed for older adults and anyone who has complex needs, including self-care deficits. The other patients do not have the complex needs of the older adult patient who has had a stroke that affects body function.

PTS: 1 DIF: Moderate REF: V1, p. 84

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Analysis

2. ANS: 3

The discharge plan may be developed in a timely manner and involve the family and a multidisciplinary team, but if the patient does not agree with the plan, it will not be successful.

PTS: 1 DIF: Moderate REF: V1, pp. 83-84 | V1, p. 90

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

3. ANS: 1

All planning is based on nursing assessment data and identified nursing diagnoses. The patient should have input, but the planning is based on the nursing assessment. The different types of planning are intertwined and may or may not be done at distinct, separate times. Discharge planning often requires a multidisciplinary team, but initial and ongoing planning may not. Initial planning is usually begun after the first patient contact, but there is no specified time for completion; ongoing planning is more or less continuous and is done as the need arises; discharge planning must be done before discharge.

PTS: 1 DIF: Moderate REF: V1, p. 81

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

4. ANS: 4

Comprehensive discharge planning should be done for patients who have a newly diagnosed chronic disease or have complex needs. The other patients may require discharge planning but not as comprehensive as someone with a new diagnosis with complex treatment.

PTS: 1 DIF: Difficult REF: V1, p. 84

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

5. ANS: 4

Standardized care plans help promote consistency of care and ensure important interventions are not forgotten. They are not likely to apply to every patient on a unit because they are usually single-problem plans or are used with a particular medical diagnosis. Unlike protocols, they do not include medical orders. Unlike critical pathways, they do not specify predicted patient outcomes for each day.

PTS: 1 DIF: Moderate REF: V1, p. 86

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Recall

6. ANS: 1

All of the statements are true for standardized care plans; but only 1 is true of both standardized care plans and unit standards of care. Both describe care needed by patients in defined situations, although unit standards usually describe care for groups of patients (e.g., all women admitted to a labor unit), and standardized care plans are often organized around a particular or all nursing diagnoses commonly occurring with a particular medical diagnosis. Unit standards are more general and do not have goals for each patient. Unit standards are kept on file in a central place on the unit and do not become a part of the care plan. Unit standards describe minimal, not ideal, care.

PTS: 1 DIF: Difficult REF: V1, p. 86; Requires analysis of text discussion.

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

7. ANS: 3

Individualizing the care plan means identifying specific problems, outcomes, and interventions and the frequency of those interventions to meet the patient’s needs. Validating data ensures your assessment is accurate. Transcribing orders is a part of developing and implementing the care plan but not of individualizing the plan. Performing an assessment is the beginning step to developing a care plan. Assessment helps you to know the ways in which a standardized plan needs to be individualized.

PTS: 1 DIF: Moderate REF: V1, p. 91

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

8. ANS: 3

Outcome statements should have specific performance criteria and a target time; “maintain oxygen saturation” is the only one that meets those criteria. The incentive spirometer goal should say how many times the incentive spirometer should be used each hour as well as the volume. The walking goal should state how far the patient should walk. In the range-of-motion goal,tolerate is a vague word and is difficult to measure, and the outcome needs to specify how often.

PTS: 1 DIF: Moderate REF: V1, p. 93

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

9. ANS: 3

Both critical pathways and standardized care plans are preplanned documents; they describe care common to all patients who have a certain condition (e.g., all patients who have a heart attack need some of the same interventions). The other statements are true of critical pathways but not of standardized nursing care plans.

PTS: 1 DIF: Difficult

REF: V1, pp. 86-87; High-level question; answer not given verbatim

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

10. ANS: 2

NOC was developed for all specialty and practice areas. The Omaha System was developed for community health nursing. Both address health restoration and can be used for individuals, family, or groups (community). Both base goals on nursing diagnoses, although Omaha does not use the NANDA taxonomy.

PTS: 1 DIF: Moderate

REF: V1, p. 96; Answer based on analysis of text discussion | V1, p. 98; Answer based on analysis of text discussion

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

11. ANS: 1

Short-term goals may be accomplished in hours or days; long-term goals usually are achieved over a week or even several months. The other statements are true for both short-term and long-term goals.

PTS: 1 DIF: Moderate REF: V1, p. 92

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

12. ANS: 4

They both provide detailed nursing interventions, although the individualized care plan is more specific to the patient’s needs and reflects critical thinking, whereas standardized plans do not. It is not true of individual nursing care plans that they are preprinted and apply to a group.

PTS: 1 DIF: Moderate REF: V1, p. 86 | V1, pp. 87-88

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

13. ANS: 1

Outcomes describe changes in the patient’s health status in response to nursing, rather than medical, interventions. Outcomes relate to patient behavior, not nursing behaviors. Outcomes are a measure of the effectiveness of nursing care for a specific nursing diagnosis, not whether the nursing diagnosis is appropriate.

PTS: 1 DIF: Easy REF: V1, p. 91

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension

14. ANS: 4

Performance criteria should be specific and measurable. (D) 75% of each meal is specific and measurable. “Frequently” is vague. You cannot observe whether someone “understands.” “Decreased” is vague; a numerical pain rating would be better.

PTS: 1 DIF: Moderate REF: V1, p. 93

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Application

15. ANS: 3

The goal for a collaborative problem is always that the complication will not occur. Other disciplines may be involved in helping to prevent the problem, but nurses still monitor for the complication. The outcomes to collaborative problems are not affected by nursing interventions alone. Goals for collaborative problems are specific to the medical condition/treatment.

PTS: 1 DIF: Moderate REF: V1, pp. 95-96

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

16. ANS: 1

Both NANDA and NOC labels are stated as human responses. A NOC label can be used to describe patient responses both before and after intervention—NANDA before. NOC statements are neutral to allow for positive, negative, or no change in health status; NANDA diagnoses describe both problem responses and positive responses (wellness labels). NANDA labels are based on patterns of related cues; NOC labels are based on (linked to) NANDA labels.

PTS: 1 DIF: Difficult

REF: V1, pp. 97-98; also information about NANDA diagnoses from Chapter 4

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

17. ANS: 2

The essential goal/outcome is aimed at the problem response Impaired Memory. The other goals in this question address the etiology.

PTS: 1 DIF: Moderate REF: V1, p. 96

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

18. ANS: 2

Informal planning is performed while doing other nursing process steps and is not written; this nurse is forming a plan in her mind. The end product of formal planning is a holistic plan of care that addresses the patient’s unique problems and strengths; this nurse has no time to create a holistic plan of care. Ongoing planning refers to changes made in the plan as you evaluate the patient’s responses to care; no care has been given at this point. Initial planning does indeed begin with the first patient contact. However, it refers to the development of the initial comprehensive plan or care; this nurse does not have enough data for a comprehensive plan, nor does she have time to make such a plan at the moment.

PTS: 1 DIF: Easy REF: V1, p. 81

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Analysis

MULTIPLE RESPONSE

1. ANS: 1, 4

ANA standard 3 includes “derives culturally appropriate expected outcomes from the diagnosis” and “involves the patient, family . . . in formulating expected outcomes. . . .” It is acceptable for the nurse to use outcomes on a clinical pathway, but these are not individualized; ANA standard 3 says that the nurse “identifies . . . outcomes for a plan individualized to the patient. . . .” The standard also says that the nurse should consider “associated risks, benefits, and costs. . . .”

PTS: 1 DIF: Moderate REF: V1, p. 82

KEY: Nursing process: Planning | Client need: SECE | Cognitive level: Comprehension