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Terms in this set (55)An elderly patient who has diabetes is admitted to the hospital with a chronic, nonhealing ulcer. The nurse inspects the color of the ulcer and measures its diameter daily. The nurse finds that the ulcer does not have an odor. The patient is taking antibiotics prescribed by the primary healthcare provider. What are the evaluative measures in relation to the ulcer in this case? Select all that apply. 1. Color of the ulcer 1, 2, 4 An elderly patient who has been taking thyroxine for hypothyroidism is diagnosed with dementia and has a caregiver. What should the nurse do in revising the care plan for hypothyroidism? Ask the caregiver to monitor administration of the thyroxine The nurse implements an intervention to relieve a patient's pressure ulcer. During the follow-up visit, the nurse observes that the patient's erythema has decreased over the past 2 days. Which step of the nursing process was utilized? Evaluation The nurse is caring for a 40-year-old patient undergoing chemotherapy. The patient complains of vomiting. Which statement is an appropriate goal statement for the patient's problem? The patient will stop vomiting in 2 hours The nurse is preparing a patient for discharge from the hospital. One of the important outcome measures before discharge is that the patient's surgical wound is aseptic. What is the most probable evaluative measure in this case? The absence of redness or tenderness at the site of the incision A patient has a nursing diagnosis of immobility secondary to a fractured ankle. As a part of the care plan, the nurse plans to assist the patient to walk and provides instruction on the use of crutches. Later, the nurse finds that the patient is already able to walk with the crutches. What should the nurse do now? Discontinue the current interventions and develop new ones Arrange the steps of the nursing process in their appropriate order. Assessment Which statement is true about the standard of care? It is the minimum acceptable level of care to ensure that a patient receives high-quality care Which is an evaluative measure used in the nursing process? Determine if nursing care was effective and patients met the expected outcomes In the nursing process, what should the nurse know about evaluation? Evaluation is dynamic and ever changing A patient has limited mobility because of a recent knee replacement. The nurse identifies that he has altered balance and assists him in ambulation. The patient uses a walker presently as part of his therapy. The nurse notes how far the patient is able to walk and then assists him back to his room. Which example is an evaluative measure? 1. Uses walker during ambulation 4. Observation of distance patient is able to walk The nurse educates a patient who has a severe wound infection about proper wound care. During the follow-up visit, the nurse observes that the symptoms of the wound infection are resolved. While communicating with the patient, the nurse finds that the patient is following proper interventions. What does the nurse infer from this finding? The patient has met the expected outcome A patient with diabetes has learned the process of preparing insulin in a syringe and administering it independently. However, the patient has developed tremors, so he can no longer administer the insulin independently and has a caregiver. How should the care plan be modified? The caregiver should prepare the insulin and inject it in the patient The nurse teaches interventions to a patient who is diagnosed with a urinary tract infection. During the follow-up visit, the patient's laboratory report shows an absence of infection. What is the appropriate nursing action in this situation? Discontinuing the care plan The nurse teaches a patient diagnosed with diabetes about the method of insulin administration. During the follow-up visit, the nurse finds that the patient is not administering insulin properly due to a psychomotor disability. What is the appropriate nursing action this situation? Ask a family member or friend to administer insulin to the patient A patient with diabetes is admitted to the hospital for management of chest pain. The patient's blood pressure (BP) is 140/88 mm Hg, and serum cholesterol is 120 mg/dL. The patient complains of mild discomfort in the lower back area. On examination, the nurse notices the skin on the patient's back has reddened and notes the potentials for pressure ulcers. What is the appropriate intervention for this patient? Change the patient's position every 2 hours Which statements correctly describe the evaluation process? Select all that apply. 1. Evaluation is an ongoing process 1, 3, 4 What should the nurse do when a goal is not met in the care of a patient? Select all that apply. 1. Reassess the patient 1, 2, 3 A patient is admitted to the hospital with a respiratory infection. Following coughing and deep-breathing exercises, the nurse finds that the patient continues to have congested lungs. What should the nurse do? Increase frequency of coughing and deep-breathing exercises During a follow-up visit, the nurse finds that the patient has symptoms of asthma despite receiving treatment to manage the disease. What is the priority nursing action? 1. Modifying the care plan Performing a reassessment The evaluation process includes interpretation of findings as one of its five elements. Which option is an example of interpretation? Matching the results of evaluative measures with expected outcomes to determine the patient's status A patient with diabetes who is immobile and does not ambulate, reports back discomfort. The nurse performs a back massage for the patient and changes the bed linens. What would be the suitable nursing-sensitive outcome for this issue? The patient will have reduced back pain A pediatric patient who sustained a wound a week ago is brought to the hospital by his mother. On examination, the nurse finds yellowish pus on the wound. His temperature is 99.9° F. The patient is crying continuously. Once the patient is discharged, the home health nurse is developing a plan of care. Since the wound is found to be infected, what should the goal statement be? The wound will completely heal by the time of discharge A patient admitted to the hospital for a respiratory infection is not meeting the expected outcomes. What should the nurse do? Select all that apply. 1. Try different therapies 1, 2, 5 The nurse knows that each time a patient is evaluated, the nursing care plan may need to be modified. What actions should the nurse perform when modifying a care plan after a patient has been evaluated? Select all that apply. 1. Evaluate the interventions 1, 2, 3 A patient who is very upset about a diagnosis of ovarian cancer is not eating adequately. The nurse had developed a care plan and set goals for this patient's psychological well-being. However, the goals were not met. What should the nurse do now? Redefine priorities for the patient. The nurse is evaluating a patient's care plan. Which action does the nurse perform to redefine the diagnosis? Revise the patient's problem list Which option is true regarding a goal that specifies the expected behavior or response? 1. The specific nursing action was completed Resolution of a nursing diagnosis or maintenance of a healthy state The nurse is caring for a patient who has recently undergone chemotherapy to treat cancer. During the follow-up visit, the patient reports frequent periods of nausea. What is the appropriate nursing action in this situation? 1. Perform a reassessment of the
patient Prepare a suitable diet plan for the patient A nursing student is talking with one of the staff nurses who works on a surgical unit. The student's care plan is to include nursing-sensitive outcomes for the nursing diagnosis of acute pain. Which option is a suitable nursing-sensitive outcome? Patient will report reduced pain severity in 2 days What should the nurse do while documenting and reporting the evaluation of interventions in the care of a patient? If a patient is not progressing, the nurse should report it to the primary health care provider. The nurse caring for a patient with pneumonia sits the patient up in bed and suctions the patient's airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which example would be appropriate evaluative criteria used by the nurse? Select all that apply. 1. Patient drinks contents of water glass 2, 4 A 60-year-old patient complains of fatigue and difficulty breathing. He is diagnosed with chronic obstructive pulmonary disease (COPD). The nurse helps the patient sit in a semi-Fowler's position, and administers oxygen therapy as prescribed by the healthcare provider. What should be the expected outcome in this patient? The patient's respiratory rate will be 22 breaths per minute The nurse is assessing a patient with a myocardial infarction. The patient's blood pressure is 130/86 mm of Hg. The patient is not experiencing pain currently. The nurse determines that the patient is able to explain the use of sublingual tablets and identifies that stress and exercise can cause chest pain. What are the evaluative measures in the patient? Select all that apply. 1. The patient's blood pressure readings 1, 2 An elderly patient is admitted to the surgical unit for an open reduction to repair a fracture of the tibia. What are the possible nursing-sensitive outcomes in this patient? Select all that apply. 1. Reduction in the frequency of pain 1, 2 The nurse is teaching a group of new nurses about modifying interventions based on the appropriateness of the intervention selected and the correct application of the intervention. Which actions does the nurse tell the new nurses are appropriate to perform? Select all that apply. 1. Continue with all existing interventions. 2, 3, 5 A patient is diagnosed with hypothyroidism. The patient has insufficient knowledge. Thus, the expected outcomes for this patient are knowledge of treatment procedures. What are the indicators that show that the patient has met the outcome of knowledge of treatment procedures? Select all that apply. 1. he patient states the health-related effects
of low thyroxine levels. 4, 5 What are the components of the evaluation phase of the nursing process? Select all that apply. 1. Determining the goals 4, 5 The nurse is caring for a 40-year-old patient undergoing chemotherapy. The patient complains of vomiting. The nurse administers antiemetic medications as ordered. However, the vomiting does not stop. If the expected goal is not met, which measures should the nurse take? Arrange the steps in proper sequence. 1. Reassess the patient The nurse is caring for a patient with acute exacerbation of gouty arthritis. The nurse has documented three expected outcomes for this patient. These include comfort level, pain control, and pain level. Which are the most appropriate indicators for pain control? Select all that apply. 1. The patient reports pain severity. 2, 4 What do unmet and partially met goals require the nurse to do? Select all that apply. 1. Redefine priorities. 1, 2 The nurse advised a patient to walk for 5 minutes at 6:00 AM every day. The next day, the patient did not follow the advice. The nurse explained to the patient the importance of walking and physical activity for health improvement. Thereafter, the patient started walking daily. What should be the next step in the care plan? 1. Ask the patient to motivate other patients to walk daily. 2. Discontinue the health education related to exercise in the care plan. A 60-year-old patient complains of difficulty breathing. He is diagnosed with chronic obstructive pulmonary disease (COPD). The nurse helps the patient sit in a semi-Fowler's position and administers oxygen therapy as prescribed by the healthcare provider. Which evaluative measures should the nurse use to measure the patient's response to nursing care? Select all that apply. 1. Observe the patient's level of comfort. 1, 2, 3 A patient comes to a health clinic with the diagnosis of asthma. The nurse practitioner decides that the patient's obesity adds to the difficulty of breathing; the patient is 5 feet 7 inches tall and weighs 200 pounds (90.7 kilograms). The practitioner plans to place the patient on a therapeutic diet. Which is an evaluative measure for determining if the patient achieves the goal of a desired weight loss? The patient is weighed during each clinic visit. A patient is admitted to the hospital for acute exacerbation of asthma. The patient outcomes include the patient being able to walk for 100 meters by the second day and not reporting breathlessness while walking. The patient's respiratory rate will remain normal while walking; the patient needs to be observed for breathlessness while walking. Which of these is an evaluative measure? The patient needs to be observed for breathlessness while walking. The nurse is caring for a patient admitted to the hospital with acute pain. If the expected outcome is reduction of the pain level for this patient, what indicators could be used to measure this outcome? Select all that apply. 1. The patient reports physical well-being. 3, 4, 5 The nurse wants to evaluate the effectiveness of the care plan in meeting the outcome goals of the patient. Arrange the steps to be taken by the nurse in their appropriate order. 1. Review the outcome criteria in the care plan to identify the desired outcomes of the patient The nurse follows a series of steps to objectively evaluate the degree of success in achieving outcomes of care. Place the steps in the correct order. 1. The nurse reviews the outcome criteria to identify the desired skin
condition ????????? A clinic nurse assesses a patient who reports a loss of appetite and a 15-pound weight loss in 2 months. The patient is 5 feet 10 inches tall and weighs 135 pounds (61.2 kilograms). She shows signs of depression and does not have a good understanding of foods to eat for proper nutrition. For the goal that the patient will return to baseline weight in 3 months, which outcomes would be appropriate? Select all that apply. 1. Patient will discuss source of depression by next clinic visit. 2, 3 A group of nursing students is learning the importance of documentation and that documentation is the last step of the evaluation process. Which example should the nurse perform when communicating the patient's progress with the patient and the family members? Select all that apply. 1. Share the patient's medical results with the patient. 1, 2, 4 A patient is admitted to the hospital for the management of chest pain. At the time of admission, the patient's blood pressure (BP) was 180/100 mm Hg. Six hours after receiving antihypertensive drugs and other medications, the BP decreased to 130/82 mm Hg. To what should the nurse interpret this response? An evaluative measure A patient who has a body mass index (BMI) of 31 complains of difficulty sleeping. The patient is asked to maintain a sleep diary. What are the evaluative measures for determining if the patient achieves restful sleep? Select all that apply. 1. Reassess the patient for any changes in diet. 3, 4 The nurse checks the intravenous (IV) solution that is infusing into the patient's left arm. The IV solution of 9% normal saline (NS) is infusing at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room, the nurse inspects the condition of the dressing and notes the date on the dressing label. In what ways did the nurse evaluate the IV intervention? Select all that apply. 1. The
nurse checked the type of IV solution. 3, 4, 5 The nurse is caring for a 40-year-old patient undergoing chemotherapy. The patient reports nausea and vomiting. The nurse administers antiemetic medications as ordered. Which criteria would the nurse use to evaluate the patient's response to the care provided? Select all that apply. 1. Goal 1, 2 A patient who has a history of eczema complains of a rash on her arms. The nurse finds that the patient has been on warfarin for the past 6 months. What should the nurse do? Measure the INR (international normalized ratio) of the patient. Sets with similar termsChapter 31 Exam Review - Environmental Emergencies95 terms helen_roberts3 Kettering (General Patient Care)56 terms keshia_lawson Foundations Chapter 20 Evaluation44 terms andreakayef Foundations Chapter 18 Planning Nursing Care44 terms andreakayef Sets found in the same folderNursing Process Part 212 terms genesissanchezgr Critical Thinking21 terms saraspencer1996 Evolve- Diagnosis39 terms jaylee_russo Ch20- EAQ41 terms erin_floyd_coley Other sets by this creatorCompliance Laws and Regulations10 terms jaylee_russo Maternal Newborn 2016 A60 terms jaylee_russo Varcarolis Chapter 17 terms jaylee_russo Abrams' Chapter 1 Vocab5 terms jaylee_russo Other Quizlet setspractice final p&c47 terms Alexia_Ten_BrinkPLUS Aveda life skills53 terms kdonovan1-aich testout section 361 terms emmaholmz Module 2: Test Your Knowledge20 terms Beatrice_Agbayewa1TEACHER Related questionsQUESTION A patient newly diagnosed with type 1 diabetes asks the nurse why he/she cannot just take a pill. The nurse would incorporate what knowledge when responding to this client? 2 answers QUESTION When you accept a job offer , request all information 3 answers QUESTION You are using an electrical microhematocrit centrifuge to spin blood. You see smoke coming from the back of the machine. What should you do? 9 answers QUESTION A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which statement is the most therapeutic? 15 answers What are the components of the evaluation phase of the nursing process?The "Planning" Phase of the nursing process is the standard for evaluation. The planning phase includes goals and outcomes. There goals and outcomes are evaluated in the evaluation process . The evaluated statement consist of 2 parts, the conclusion and supporting data.
Which are purposes of the evaluation phase of the nursing process select all that apply?The purpose of the evaluation step of the nursing process is to: (Select all that apply.) determine if outcomes have been reached and the goals are met. compare actual outcomes with expected outcomes. confirm that nursing interventions are effective.
What are the components of nursing process?These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.
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What are the components of the evaluation phase of the nursing process select all that apply?
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