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Chapter 20 Evaluation-Fundamentals of Nursing

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Chapter 20 Evaluation-Fundamentals of Nursing











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Chapter 20: Evaluation
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MULTIPLE CHOICE ra




1. A nursing attendant determines that the hospital client ’s condition has improved and has me
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t expected outcomes. Which step of the nursing process is the nursing attendant exhibiting
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? a. Assessment
b. Planning
c. Implementation
d. Evaluation


ACCURATE ANSWER:-D ra



Evaluation, the final step of the nursing process, is crucial to determine whether, after applic
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ation of the first four steps of the nursing process, a hospital client ’s condition or well being imp
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roves and if goals have been met. Assessment, the first step of the process, includes d
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ata collection. Planning, the third step of the process, involves setting priorities, identifying h
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ospital client goals and outcomes, and selecting nursing interventions. During implementati
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on, nursing attendant s carry out nursing care, which is necessary to help hospital client s ac
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hieve their goals. ra ra




DIF:Understand (comprehension) ra



OBJ:Examine the relationship between critical thinking, clinical judgment and evaluation of nursing
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care. TOP:Evaluation MSC: Management of Care ra ra




2. A nursing attendant completes a thorough database and carries out nursing intervention
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s based on priority diagnoses. Which action will the nursing attendant take next? a.
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Assessment
b. Planning
c. Implementation
d. Evaluation
ACCURATE ANSWER:-D ra



Evaluation, the final step of the nursing process, is crucial to determine whether, after applicati
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on of the first four steps of the nursing process, a hospital client ’s condition or well being improv
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es. Assessment involves gathering information about the hospital client . During t
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he planning phase, hospital client outcomes are determined. Implementation involves carrying
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out appropriate nursing interventions.
ra ra ra




DIF:Understand (comprehension) ra



OBJ:Examine the relationship between critical thinking, clinical judgment and evaluation of nursing
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care. TOP:Evaluation MSC: Management of Care ra ra




3. A novice nursing attendant asks the preceptor to describe the primary purpose o
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f evaluation. Which statement made by the nursing preceptor is most accurate?
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―An evaluation helps you determine whether all nursing interventions were
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completed.‖
b. ―During evaluation, you determine when to downsize staffing on nursing units.‖
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, c. ―Nursing attendant s use evaluation to determine the effectiveness of nursing care.‖ ra ra ra ra ra ra ra ra ra ra ra




d. ―Evaluation eliminates unnecessary paperwork and care planning.‖ ra ra ar ra ra ra




ACCURATE ANSWER:-C ra



Evaluation is a methodical approach for determining if nursing implementation was effective
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in influencing a hospital client ’s progress or condition in a favorable way. During evaluation, y
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ou do not simply determine whether nursing interventions were completed. The evaluation p
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rocess is not used to determine when to downsize staffing or how to eliminate paperwork an
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d care planning.
ra ra




DIF:Understand (comprehension) ra



OBJ:Examine the relationship between critical thinking, clinical judgment and evaluation of nursing
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care. TOP:Teaching/Learning MSC: Management of Care ra ra ra




4. After assessing the hospital client and identifying the need for headache relief, the nursin
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gar



attendant administers acetaminophen. Which action by the nursing attendant is priorit
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y f or this hospital client ?
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a. Eliminate headache from the nursing care plan. ra ra ra ra ra ra




b. Direct the nursing assistive personnel to ask if the headache is relieved.
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c. Reassess the hospital client ’s pain level in 30 minutes. ra ra ra ra ra ra ra ra ra




d. Revise the plan of care. ra ra ra ra




ACCURATE ANSWER:-C ra



The nursing attendant ’s priority action for this hospital client is to evaluate whether the nur
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sing intervention of administering acetaminophen was effective. The nursing attendant does
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not have enough evaluative data at this point to determine whether headache needs to be disc
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ontinued. Assessment is the nursing attendant ’s responsibility and is not to be delegated to n
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ursing assistive personnel. The nursing attendant does not have enough evaluative data to det
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ermine whether the hospital client ’s plan of care needs to be revised.
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DIF:Apply (application) ra



OBJ:Examine the relationship between critical thinking, clinical judgment and evaluation of nursing
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care. TOP:Evaluation MSC: Basic Care and Comfort ra ra ra




5. A nursing attendant is getting ready to discharge a hospital client who is experiencing
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impaired physical mobility. What does the nursing attendant need to do before disco
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ntinuing the hospital client ’s plan of care? ra ra ra ra ra ra ra




a. Determine whether the hospital client has transportation to get home. ra ra ra ra ra ra ra ra ra




b. Evaluate whether hospital client goals and outcomes have been met. ra ra ra ra ra ra ra ra ra




c. Establish whether the hospital client has a follow-up appointment scheduled. ra ra ra ra ra ra ra ra ra




d. Ensure that the hospital client ’s prescriptions have been filled to take home.
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ACCURATE ANSWER:-B ra



You evaluate whether the results of care match the expected outcomes and goals set for a hos
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pital client before discontinuing a hospital client ’s plan of care. The hospital client needs tran
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sportation, but that does not address the hospital client ’s mobility status. Whether the hospi
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tal client has a followup appointment and ensuring that prescriptions are filled do not evaluate t
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he problem of mob ility.
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DIF:Apply (application) ra



OBJ:Discuss the process of determining the need to revise a hospital client ’s plan o
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f care. TOP:Evaluation MSC: Management of Care
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, 6. The nursing attendant is evaluating whether hospital client goals and outcomes have bee
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n met for a hospital client
ar ra with impaired physical mobility due to a fractured leg.
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Which fi nding indicates the hospital client has met an expected outcome?
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a. The nursing attendant provides assistance while the hospital client is walking in the
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hallways.
b. The hospital client is able to ambulate in the hallway with crutches.
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c. The hospital client will deny pain while walking in the hallway.
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d. The hospital client ’s level of mobility will improve.
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ACCURATE ANSWER:-B ra



The hospital client ’s being able to ambulate in the hallway with crutches is an expected out
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come of nursing care. The outcomes of nursing practice are the measurable conditions of hos
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pital client , family or community status, behavior, or perception. These outcomes are the crite
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ria used to judge success in delivering nursing care. The option stating, ―The hospital client
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’s level of mobility will improve‖ is a broader goal statement. The nursing attendant ’s assistin
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g a hospital client to ambulate is an intervention. The hospital client ’s denying pain is an ex
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pected outcome for pain, not for physical mobility problems.
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DIF:Apply (application) ra



OBJ:Examine the relationship between critical thinking, clinical judgment and evaluation of nursing
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r


care. TOP:Evaluation MSC: Management of Care ra ra




7. The nursing attendant is evaluating whether a hospital client ’s turning schedule was effec
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tive in preventing the formation of pressure ulcers. Which finding indicates success of the t
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urning schedule? ra




a. Staff documentation of turning the hospital client every 2 hours
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b. Presence of redness only on the heels of the hospital client ra ra ra ra ra ra ra ra ra ra




c. Hospital client understands the need for regular turning ra ra ra ra ra ra ra




d. Absence of skin breakdown ra ra ra




ACCURATE ANSWER:-D ra



To determine whether a turning schedule is successful, the nursing attendant needs to assess
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for the presence of skin breakdown. Redness on any part of the body, including only the hospi
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tal client ’s heels, indicates that the turning schedule was not successful. Documentation of in
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terventions does not evaluate whether hospital client outcomes were met. While it is helpful
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that the hospital client understands the importance of the intervention, it is not criteria for suc
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cessfulness of the turning schedule. ra ra ra ra




DIF:Analyze (analysis) ra



OBJ:Analyze the relationship among expected outcomes and evaluative measures when evaluating
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nursing care. TOP:Evaluation MSC: Basic Care and Comfort
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8. A nursing attendant has instituted a turn schedule for a hospital client to prevent skin brea
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k
down. Upon evaluation, the nursing attendant finds that the hospital client has a stage II p
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ress ure ulcer on the buttocks. Which action will the nursing attendant take next? a.
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Reassess the hospital client and situation. ra ra ra ra ra




b. Revise the turning schedule to increase the frequency.ra ra ra ra ra ra ra




c. Delegate turning to the nursing assistive personnel. ra ra ra ra ra ra




d. Apply medication to the area of skin that is broken down.
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