C HAPTER 20: E VALUATION
Potter: Fundamentals of Nursing, 11th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient whose plan of care states that a change of
dressing is to occur twice a day, at 0600 and 1800. At 1400, the nurse
notices that the dressing is saturated and leaking . What is the nurse’s next
action?
a. Wait and change the dressing at 1800 as ordered.
b. Revise the plan of care and change the dressing now.
c. Reassess the dressing and the wound in 2 hours.
d. Discontinue the plan of care for wound care.
ANS: B
Because the dressing is saturated and leaking, the nurse needs to revise
the plan of care and change the dressing now. Reflection -in-action
involves a nurse’s abilit y to recognize how a patient is responding and
then adjusting interventions as a result. A nurse will either change the
frequency of an intervention, change how the intervention is delivered,
or select a new intervention. Waiting until 1800 or for another 2 hours
is not appropriate because assessment data reflect that the dressing is
saturated and needs to be ch anged now. Data are insufficient to support
discontinuing the plan of care. Instead, data at this time indicate the
need for revision of the plan of care.
, DIF: Anal yze (anal ysis) OBJ: Discuss the process of determining
the need to revise a patient’s plan of care. TOP: Evaluation
MSC: Basic Care and Comfort
2. A goal for a patient diagnosed with diabetes is to demonstrate effective
coping skills. Which patient behavior will indicate to the nurse
achievement of this outcome?
a. States, “It reall y helps talking about m y health with famil y and
friends.”
b. Observed consuming high -carbohydrate foods when stressed.
c. Expresses a dislikes with the support group meetings.
d. Spends most of the day reading in bed.
ANS: A
Evaluative data that show signs of effective coping wi ll help the nurse
determine whether the patient has met the outcome. Talking to famil y
and friends is the only positive option. During evaluation, you perform
evaluative measures that allow you to compare clinical data, patient
behavior measures, and patie nt self-report measures collected before
implementation with the evaluation findings gathered after
administering nursing care. Next, you evaluate whether the results of
care match the expected outcomes and goals set for a patient.
Consuming high-carbohydrate foods (patient is a diabetic), disliking
support group, and spending the day in bed indicate unsuccessful
progress toward meeting the patient’s goal.
DIF: Appl y (application) OBJ: Explain the importance of
using the correct evaluative measures. TOP: Evaluation
MSC: Management of Care
, 3. A nurse is providing education to a patient about self -administering
subcutaneous injections. The patient demonstrates the self -injection.
Which t ype of indicator did the nurse evaluate?
a. Health status
b. Health behavior
c. Ps ychological self -control
d. Health service utilization
ANS: B
Health behavior involves demonstrating a psychomotor skill such as
self-injection. Health status is a clinical indicator such as exercise
tolerance or blood pressure control. The skill is psychom otor, not
ps ychological self -control. Health service utilization is readmission
within 30 days or emergency department use.
DIF: Understand (comprehension) OBJ: Explain the
importance of using the correct evaluative measures. TOP:
Evaluation MSC: Management of Care
4. A nurse is evaluating the goal of acceptance of body image in a young
teenage girl. Which statement made by the patient is the best indicator of
progress toward the goal?
a. “I’m worried about what those other girls will think of me. ”
b. “I can’t wear dresses that make m y hips stick out. ”
c. “I’ll wear the blue dress. It matches m y eyes. ”
d. “I hope I can go to the pool next summer. ”
ANS: C
Potter: Fundamentals of Nursing, 11th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient whose plan of care states that a change of
dressing is to occur twice a day, at 0600 and 1800. At 1400, the nurse
notices that the dressing is saturated and leaking . What is the nurse’s next
action?
a. Wait and change the dressing at 1800 as ordered.
b. Revise the plan of care and change the dressing now.
c. Reassess the dressing and the wound in 2 hours.
d. Discontinue the plan of care for wound care.
ANS: B
Because the dressing is saturated and leaking, the nurse needs to revise
the plan of care and change the dressing now. Reflection -in-action
involves a nurse’s abilit y to recognize how a patient is responding and
then adjusting interventions as a result. A nurse will either change the
frequency of an intervention, change how the intervention is delivered,
or select a new intervention. Waiting until 1800 or for another 2 hours
is not appropriate because assessment data reflect that the dressing is
saturated and needs to be ch anged now. Data are insufficient to support
discontinuing the plan of care. Instead, data at this time indicate the
need for revision of the plan of care.
, DIF: Anal yze (anal ysis) OBJ: Discuss the process of determining
the need to revise a patient’s plan of care. TOP: Evaluation
MSC: Basic Care and Comfort
2. A goal for a patient diagnosed with diabetes is to demonstrate effective
coping skills. Which patient behavior will indicate to the nurse
achievement of this outcome?
a. States, “It reall y helps talking about m y health with famil y and
friends.”
b. Observed consuming high -carbohydrate foods when stressed.
c. Expresses a dislikes with the support group meetings.
d. Spends most of the day reading in bed.
ANS: A
Evaluative data that show signs of effective coping wi ll help the nurse
determine whether the patient has met the outcome. Talking to famil y
and friends is the only positive option. During evaluation, you perform
evaluative measures that allow you to compare clinical data, patient
behavior measures, and patie nt self-report measures collected before
implementation with the evaluation findings gathered after
administering nursing care. Next, you evaluate whether the results of
care match the expected outcomes and goals set for a patient.
Consuming high-carbohydrate foods (patient is a diabetic), disliking
support group, and spending the day in bed indicate unsuccessful
progress toward meeting the patient’s goal.
DIF: Appl y (application) OBJ: Explain the importance of
using the correct evaluative measures. TOP: Evaluation
MSC: Management of Care
, 3. A nurse is providing education to a patient about self -administering
subcutaneous injections. The patient demonstrates the self -injection.
Which t ype of indicator did the nurse evaluate?
a. Health status
b. Health behavior
c. Ps ychological self -control
d. Health service utilization
ANS: B
Health behavior involves demonstrating a psychomotor skill such as
self-injection. Health status is a clinical indicator such as exercise
tolerance or blood pressure control. The skill is psychom otor, not
ps ychological self -control. Health service utilization is readmission
within 30 days or emergency department use.
DIF: Understand (comprehension) OBJ: Explain the
importance of using the correct evaluative measures. TOP:
Evaluation MSC: Management of Care
4. A nurse is evaluating the goal of acceptance of body image in a young
teenage girl. Which statement made by the patient is the best indicator of
progress toward the goal?
a. “I’m worried about what those other girls will think of me. ”
b. “I can’t wear dresses that make m y hips stick out. ”
c. “I’ll wear the blue dress. It matches m y eyes. ”
d. “I hope I can go to the pool next summer. ”
ANS: C
