Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. Which of the following outcomes best reflects a nurse-sensitive client
outcome?
A. Client will consume 75% of all meals.
B. Client will perform personal hygiene daily.
C. Client will experience no falls during hospitalization.
D. Client will report lessened anxiet y regarding surgical procedure.
ANS: C
A nurse-sensitive client outcome is a measurable client or famil y state,
behavior, or perception largel y influenced by and sensitive to nursing
interventions. The nurse is instrumental in the prevention of falls while
the remaining options are dependent on the clie nt.
DIF: C dm 293 OBJ: Anal ysis TOP: Nursing Process: Evaluation
MSC: NC LEX test plan designation: Safe, Effective Care
Environment
2. The nurse has identified a nursing diagnosis of knowledge deficit
regarding the need to monitor blood glucose levels dai l y. Which of the
following statements best reflects the clients understanding of the need for
therapy?
, A. Client agrees to test blood glucose levels 4 times a day.
B. Client records blood glucose levels for a 3 -week period.
C. Client is observed testing his blood g lucose level before breakfast.
D. Client is able to demonstrate the proper technique for performing a
finger stick.
ANS: B
During the planning phase of the nursing process it is important for
you to select an observable client state, behavior, or self -reported
perception that will reflect goal achievement. The actual written result
of regular blood glucose monitoring is the best indicator of the clients
understanding of the importance of regular testing. The remaining
options may show initial willingness or abilit y to perform the test but
do not show consistent compliance.
DIF: C dm 293 OBJ: Anal ysis TOP: Nursing Process: Evaluation
MSC: NC LEX test plan designation: Safe, Effective Care
Environment
3. Which of the following nursing notes demonstrates the bes t evaluation of
nursing interventions regarding the care provided?
A. Pressure ulcer located on left heel has shown improvement.
B. Pressure ulcer located on left heel has responded to treatment.
C. Pressure ulcer on left heel is no longer producing purulent draina ge.
D. Pressure ulcer on left heel has not enlarged in size within the last 24
hours.
ANS: C
, In many clinical situations it is important to collect evaluative
measures over a period of time to determine if a pattern of
improvement or change exists. The abse nce of purulent drainage
indicates successful nursing interventions while the other options
either fail to provide measurable data regarding the wound or indicate
no improvement.
DIF: C REF: 294 OBJ: Anal ysis TOP: Nursing Process:
Evaluation MSC: NC LEX test plan designation: Safe, Effective
Care Environment
4. Which of the following statements made by a clients famil y is the most
reliable for use in the evaluation of a clients outcome?
A. Mom has been eating 90% of all of her meals since shes been home.
B. My daughter is in much less pain now that she is going to physical
therapy.
C. My husband has been less depressed since hes been on that
antidepressant pill.
D. Mom has been so much better since shes been able to get up and
walk by herself.
ANS: A
Input from the family and other caregivers can be used to evaluate
client outcomes but it is best to use their observations of measurable
actions, such as the amount eaten, than to rel y on their subjective
opinions of a clients reaction, such as pain, anxiet y, or mood.