Outcome Identification and Planning

1.

One of the primary factors that the nurse considers when setting priorities for the patient in the acute care setting after cardiac surgery is the patient’s
A)
Support system
B)
Medical orders
C)
Past medical history
D)
Condition
Ans:
D

Feedback:

Because a person’s condition changes, priorities change. Priorities are based on information collected during reassessment.

2.

The clinical nursing plan of care used by the registered nurse differs from the instructional nursing plan of care prepared by nursing students in 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
Ans:
A

Feedback:

In clinical settings, nurses may use rationales to illustrate research findings or support controversial approaches to problems.

3.

When a nurse assists a postoperative patient to the chair, which type of nursing intervention does this represent?
A)
Maintenance
B)
Surveillance
C)
Psychomotor
D)
Psychosocial
Ans:
C

Feedback:

Psychomotor interventions include activities such as positioning, inserting, and applying.

4.

A nurse is demonstrating foley catheter care to a patient. Which type of nursing intervention does this best represent?
A)
Surveillance
B)
Maintenance
C)
Supervisory
D)
Educational
Ans:
D

Feedback:

Demonstrating, teaching, and observing a return demonstration are classified as educational interventions.

5.

A treatment based on a nurse’s clinical judgment and knowledge to enhance patient outcomes is a nursing:
A)
Diagnosis
B)
Evaluation
C)
Intervention
D)
Goal
Ans:
C

Feedback:

A nursing intervention is any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/patient outcomes.

6.

The most basic level of nursing interventions is
A)
Physiologic
B)
Behavioral
C)
Safety
D)
Family
Ans:
A

Feedback:

The most basic domain of the seven domains of Nursing Intervention Classifications is physiologic: basic.

7.

What are specific measurable and realistic statements of goal attainment?
A)
Nursing diagnoses
B)
Nursing interventions
C)
Evaluation
D)
Outcome criteria
Ans:
D

Feedback:

Outcome criteria are specific, measurable, realistic statements of goal attainment.

8.

When establishing patient outcomes with the patient, 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
Ans:
D

Feedback:

The qualifier is a description of the parameter for achieving the outcome.

9.

What is the purpose of the patient 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
Ans:
A

Feedback:

A patient outcome addresses the problem stated in the nursing diagnosis.

10.

For the postoperative patient, which of the following nursing diagnoses 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
Ans:
B

Feedback:

In this scenario, ineffective breathing patterns will promote the development of pneumonia in the postoperative phase.

11.

Which of the following nursing diagnosis is high priority?
A)
Spiritual distress
B)
Stress incontinence
C)
Anxiety
D)
Ineffective breathing patterns
Ans:
D

Feedback:

High-priority nursing diagnoses are those that are potentially life-threatening and require immediate action.

12.

A patient is scheduled for surgery for an abdominal hysterectomy. During the preoperative assessment, the patient states, “I am very nervous and scared to have surgery.” What patient outcome is the priority?
A)
Evaluate the need for antibiotics
B)
Resolve the patient’s anxiety
C)
Provide preoperative education
D)
Prepare the patient for surgery
Ans:
B

Feedback:

A priority is something that takes precedence in position, deemed the most important among several items. The patient’s preparation for surgery is important, but to have a successful outcome, the nurse must address the psychosocial issues related to anxiety.

13.

The Nursing-Sensitive Outcomes Classification system organizes outcomes by
A)
Nursing diagnosis
B)
Medical diagnosis
C)
Critical pathway
D)
Measurement activities
Ans:
D

Feedback:

The outcomes are organized according to categories, classes, labels, outcome indicators, and measurement activities for outcomes.

14.

A computerized information system developed to classify patient outcomes is the
A)
North American Nursing Diagnoses List
B)
Nursing-Sensitive Outcomes Classification
C)
McCaffery Pain Management Scale
D)
Outcome Criteria Listing Source
Ans:
B

Feedback:

The Nursing-Sensitive Outcomes Classification system is organized according to categories, classes, labels, outcome indicators, and measurement activities for outcomes.

15.

A nurse identifies outcomes of care for the hospitalized, postoperative patient primarily to
A)
Document nursing practice
B)
Evaluate nursing interventions
C)
Focus on health promotion
D)
Provide individualized care
Ans:
D

Feedback:

Outcome identification also promotes participation, provides care plans that are realistic and measurable, and allows for involvement of support people.

16.

A patient 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
Ans:
A

Feedback:

The family is aware of the patient’s past experiences and accomplishments. Thus, the nurse should allow for the involvement of support people, particularly family.

17.

When a nurse notices the patient 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
Ans:
D

Feedback:

In this scenario, pain management is the priority. In outcome identification, activities performed include establishing priorities.

18.

A patient is rehabilitating from a fractured right leg. She is learning to walk on crutches. Together, the patient and the nurse have established a plan for the patient to walk with a three-point gait for 20 feet by the next day. In outcome identification, what is this termed?
A)
Establishing a patient goal
B)
Evaluation of crutch training
C)
Collaboration with physical therapy
D)
Implementation of crutch walking
Ans:
A

Feedback:

The activity in outcome identification is the establishment of patient goals and outcome criteria.

19.

Planning care in the outcome identification phase allows
A)
Implementation of nursing interventions
B)
Promotion of patient participation in care
C)
The diagnostic process to progress
D)
The identification of proper diagnoses
Ans:
B

Feedback:

Outcome identification serves the purpose of promoting patient participation.