Chapter 18 Planning and Outcomes Identification in Nursing Care-Fundamentals of Nursing

Chapter 18: Planning and Outcomes Identification in Nursing Care
ra ra ra ra ra ra ra ra ra




MULTIPLE CHOICE ra




1. The nursing attendant completes a thorough assessment of a hospital client and anal
ra ra ra ra ra ra ra ra ra ra ra ra



yzes the data to identify nursing diagnoses. Which step will the nursing attendant tak
ra ra ra ra ra ra ra ra ra ra ra ra ar



e next in the nursing process?
ra ra ra ra ra




a. Assessment
b. Diagnosis
c. Planning
d. Implementation
ACCURATE ar



ANSWER:-C
After identifying a hospital client ’s nursing diagnoses and collaborative problems, a nursing a
ra ra ra ra ra ra ra ra ra ra ra ra ra



ttendant prioritizes the diagnoses, sets hospital client centered goals and expected outcomes, an
ra ra ra ra ra ra ra ra ra ra ra ar



d chooses nursing interventions appropriate for eac
ra ra ra ra ra ra



h diagnosis. This is the third step of the nursing process, planning. The assessment phase of t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



he nursing process involves gathering data. The implementation phase involves carrying out a
ra ra ra ra ra ra ra ra ra ra ra ra



ppropriate nursing interventions. ra ra



During the evaluation phase, the nursing attendant assesses the achievement of goals and effectiv
ra ra ra ra ra ra ra ra ra ra ra ra ar



e ness of interventions. ra ra




DIF:Understand (comprehension) ra



OBJ:Explain the relationship of planning to nursing diagnosis. ra ra ra ra ra ra ra ar



TOP:Planning MSC: Management of Care ra ra ra




2. A hospital client ’s plan of care includes the goal of increasing mobility this shift. As the hos
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



pital client is ambulating to the bathroom at the beginning of the shift, the hospital client fall
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar



s. Which initial action will the nursing attendant take next to most effectively revise the pl
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



an of care? ra ra




a. Consult physical therapy. ra ra




b. Establish a new plan of care. ra ra ra ra ra




c. Set new priorities for the hospital client .
ra ra ra ra ra ra ra




d. Assess the hospital client . ra ra ra ra




ACCURATE ar



ANSWER:-D
Nursing attendant s revise a plan when a hospital client ’s status changes; assessment is the fi
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



rst step. Know also that a plan of care is dynamic and changes as the hospital client ’s needs c
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar



hange. Asking physical therapy to assist the hospital client is premature before assessing the h
ra ra ra ra ra ra ra ra ra ra ra ra ra ar



ospital client and awaiting the health care provider’s orders. The nursing attendant may not
ra ra ra ra ra ra ra ra ra ra ra ra ra ra



need to disregard all previous diagnoses. Some diagnoses may still apply, but the hospital clie
ra ra ra ra ra ra ra ra ra ra ra ra ra ra



nt needs to be assessed first. Setting new priorities is not recommended before assessment
r a ra ra ra ra ra ra ra ra ra ra ra ra ra



and establishing diagnoses.
ra ra




DIF:Apply (application) ra OBJ:Discuss criteria used in priority setting. ra ra ra ra ra

, TOP:Planning MSC: Management of Care ra ra ra




3. Which information concerning a goal indicates a nursing attendant has a good
ra ra ra ra ra ra ra ra ra ra ra ar



understanding of its purpose? ra ra ra




a. It is a statement describing the hospital client ’s accomplishments without a time restriction.
ra ra ra ra ra ra ra ra ra ar ra ra ra




b. It is a realistic statement predicting any negative responses to treatments.
ra ra ra ra ra ra ra ra ra ra




c. It is a broad statement describing a desired change in a hospital client ’s behavior.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra




d. It is a measurable change in a hospital client ’s physical state.
ra ra ra ra ra ra ra ra ra ra ra




ACCURATE ANSWER:-C ra



A goal is a broad statement that describes a desired change in a hospital client ’s condition or
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar



behavior. A goal is mutually set with the hospital client . An expected outcome is the measur
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



able changes (hospital client behavior, physical state, or perception) that must be achieved t
ra ra ra ra ra ra ra ra ra ra ra ra ra



o reach a goal. Expected outcomes are time limited, measurable ways of determining if a goal
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



is met. ra




DIF:Understand (comprehension) ra



OBJ:Explain how clinical judgment is integral to the planning process.ra ra ra ra ra ra ra ra ra ar



TOP:Planning MSC: Management of Care ra ra ra




4. A nursing attendant is developing a care plan for a hospital client prescribed bed rest
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar



as a result of a pelvic fracture. Which goal statement is realistic for the nursing atten
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



dant to assign to this hospital client ?
ra ra ra ra ra ra ra




a. Hospital client will increase activity level this shift. ra ra ra ra ra ra ra




b. Hospital client will turn side to back to side with assistance every 2 hours.
ra ra ra ra ra ra ra ra ra ra ra ra ra




c. Hospital client will use the walker correctly to ambulate to the bathroom as needed.
ra ra ra ra ra ra ra ra ra ra ra ra ra




d. Hospital client will use a sliding board correctly to transfer to the bedside
ra ra ra ra ra ra ra ra ra ra ra ra ar



commode as needed. ra ra




ACCURATE ANSWER:-A ra



A goal is a broad statement of desired change; the hospital client will increase activity level is a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar r



broad statement. Turning is the expected outcome. When determining goals, the nursing att
a ra ra ra ra ra ra ra ra ra ra ra ra



endant needs to ensure that the goal is individualized and realistic for the hospital client .
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



Since the hospital client is on bed rest, using a walker and bedside commode is contraindicate
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar



d.

DIF:Apply (application) ra



OBJ:Examine the relevance of outcomes selected for nursing diagnoses. T ra ra ra ra ra ra ra ra ar



OP:Planning MSC: Management of Care ra ra ra




5. The following statements are on a hospital client ’s nursing care plan. When creating a
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



nursing care plan, which statement should the nursing attendant use as an outcome for
ra ra ra ra ra ra ra ra ra ra ra ra ra ra



a goal of care?
ar ra ra




a. The hospital client will verbalize a decreased pain level less than 3 on a 0 to 10 sc
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar



ale by the end of this shift. ra ra ra ra ra ra




b. The hospital client will demonstrate increased tolerance to activity over the next month.
ra ra ra ra ra ra ra ra ra ra ra ra




c. The hospital client will understand needed dietary changes by discharge.
ra ra ra ra ra ra ra ra ra




d. The hospital client will demonstrate increased mobility in 2 days.
ra ra ra ra ra ra ra ra ra




ACCURATE ANSWER:-A ra



An expected outcome is a specific and measurable change that is expected as a result of nur
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



sing care. Verbalizing decreased pain on a 0 to 10 scale is an outcome. The other three optio
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra

, ns in this question are goals. Demonstrating increased mobility in 2 days and understanding
ra ra ra ra ra ra ra ra ra ra ra ra ra



necessary dietary changes by discharge are short-
ra ra ra ra ra ra ra



term goals because they are expected to occur in less than a week. Demonstrating increased
ra ra ra ra ar ra ra ra ra ra ra ra ra ra ra



tolerance to activity over a month- ra ra ra ra ra



long period is a longterm goal because it is expected to occur over a longer period of time.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar




DIF:Apply (application) ra



OBJ:Examine the relevance of outcomes selected for nursing diagnoses. T ra ra ra ra ra ra ra ra ar



OP:Planning MSC: Management of Care ra ra ra




6. A charge nursing attendant is reviewing outcome statements written by a novice nursin
ra ra ra ra ra ra ra ra ra ra ra ra



g attendant . The nursing attendant is using the SMART approach. Which hospital clie
ar ra ra ra ra ra ra ra ra ra ra ra ra



nt outcome statement will the charge nursing attendant identify as appropriate to the n
ra ra ra ra ra ra ra ra ra ra ra ra ra



ew nursing attendant ?
ra ra ra




a. The hospital client will ambulate in hallways. ra ra rara ra ra ra




b. The nursing attendant will monitor the hospital client ’s heart rhythm continuously this shift
ra ra ra ra ra ra ra ra ra ra ra ra ra



.
c. The hospital client will feed self at all mealtimes today without reports of s
ra ra ra ra ra ra ra ra ra ra ra ra ar



hortness of breath. ra ra




d. The nursing attendant will administer pain medication every 4 hours to keep th
ra ra ra ra ra ra ra ra ra ra ra ra



e hospital client free from discomfort.
ar ra ra ra ra




ACCURATE ANSWER:-C ra



An expected outcome should be hospital client centered; should address one hospital client r
ra ra ra ra ra ra ra ra ra ra ra ra ra



esponse; should be specific, measurable, attainable, realistic, and timed (SMART approach). T
ra ra ra ra ra ra ra ra ra ra ar



he statement ra




―The hospital client will feed self at all mealtimes today without reports of shortness of breat
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



h‖ includes all SMART criteria for goal writing. ―The hospital client will ambulate in hallway
ra ra ra ra ra ra ra ra ra ra ra ra ra ra



s‖ is missing a time limit. Administering pain medication and monitoring the hospital client ’s
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



heart rhythm are nursing interventions; they do not reflect hospital client behaviors or actions.
ra ra ra ra ra ra ra ra ra ra ra ra ar




DIF:Analyze (analysis) ra



OBJ:Use the SMART model for writing outcome statements. ra ra ra ra ra ra ra



TOP:Planning ar



MSC: Management of Care ra ra ra




7. A nursing assessment for a hospital client with a spinal cord injury leads to several pertinent
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra a



n ursing diagnoses. Which nursing diagnosis is the highest priority for this hospital client ?
r ra ra ra ra ra ra ra ra ra ra ra ra ra



a. Risk for impaired skin integrity ra ra ra ra




b. Risk for infection ra ra




c. Spiritual distress ra




d. Reflex urinary incontinence ra ra




ACCURATE ANSWER:-D ra



Reflex urinary incontinence is highest priority. If a hospital client ’s incontinence is not addre
ra ra ra ra ra ra ra ra ra ra ra ra ra ra



ssed, then the hospital client is at higher risk of impaired skin integrity and infection. Remem
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra



ber that the Risk for diagnoses are potential problems. They may be prioritized higher in some
ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra ra



cases but not in this situation. Spiritual distress is an actual diagnosis, but the adverse effects t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra



hat could result from not assisting the hospital client with urinary elimination take priority i
ra ra ra ra ra ra ra ra ra ra ra ra ra ra



n this case.
ra ra




DIF:Analyze (analysis) ra