Nur1025 - T2 - Ch. 20 - Evaluation

Front 1

C1. A nurse caring for a pt with pneumonia sits the pt up in bed and suctions his airway. After suctioning, the pt describes some discomfort in his abdomen. The nurse auscultates the pt's lung sounds and gives him a glass of water. Which of the following is an evaluative measure used by the nurse?
1. Suctioning the airway
2. Sitting pt up in bed
3. Auscultating lung sounds
4. Pt describing type of discomfort

Back 1

3. Auscultating lung sounds

Front 2

C2. A nurse caring for a pt with pneumonia sits the pt up in bed and suctions the pt's airway. After suctioning the pt describes some discomfort in his abdomen. The nurse auscultates the pt's lung sounds and gives him a glass of water. Which of the following would be appropriate evaluative criteria used by the nurse? Select all that apply.

1. Pt drinks contents of water glass.
2. Pt's lungs are clear to auscultation in bases.
3. Pt reports abdominal pain on scale of 0 - 10.
4. Pt's rate and depth of breathing are normal with head of bed elevated.

Back 2

2. and 4.

Front 3

C3. The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of interpretations?
1. Evaluating the pt's response to selected nursing interventions
2. Selecting an observable or measurable states or behavior that reflects goal achievement
3. Reviewing the pt's nursing diagnoses and establishing goals and outcomes statements
4. Matching the results of evaluative measures with expected outcomes to determine pt's status.

Back 3

4. Matching the results....

Front 4

C4. A goal specifies the expected behavior or response that indicates:

1. The specific nursing action was completed.
2. The validation of the nurse's physical assessment
3. The nurse has made the correct nursing diagnoses.
4. Resolution of a nursing diagnoses or maintenance of a healthy state.

Back 4

4. Resolution of a nursing diagnosis or maintenance of a healthy state

Front 5

C5. A pt is recovering from surgery for removal of an ovarian tumor. It is 1 day after her surgery. Because she has an abdominal incision and dressing and a history of diabetes, the nurse has selected a nursing diagnosis of "risk for infection." Which of the following is an appropriate goal statement for the diagnosis?
1. Pt will remain afebrile to discharge.
2. Pt's wound will remain free of infection by discharge.
3. Pt will receive ordered antibiotic on time over next 3 days.
4. Pt's abdominal incision will be covered with a sterile dressing for 2 days.

Back 5

2. Pt's wound will remain free of infection by discharge.

Front 6

C6. Unmet and partially met goals require the nurse to do which of the following? (Select all that apply)

1. Redefine priorities
2. Continue intervention
3. Discontinue care plan
4. Gather assessment data on a different nursing diagnosis.
5. Compare the pt's response with that of another pt

Back 6

1. Redefine priorities
2. Continue intervention

Front 7

C7. A pt comes to a medical clinic with the diagnosis of asthma. The nurse practitioner decides that the pt's obesity adds to the difficulty of breathing; the pt is 5 feet 7 inches tall and weighs 200 lbs. Based on the nursing diagnosis of imbalanced nutrition: more than body requirements, the practitioner plans to place the pt on a therapeutic diet. Which of the following are evaluative measures for determining if the pt achieves the goal of a desired weight loss? (select all that apply)

1. The pt eats 2000 calories a day.
2. The pt is weighed during each clinic visit.
3. The pt discusses factors that increase the risk of an asthma attack.
4. The pt's food diary that tracks intake of daily meals is reviewed.

Back 7

4. The pt's food diary that tracks intake of daily meals is reviewed.

Front 8

C8. 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 judges the extent to which the condition of the skin matches the outcome criteria.
2. The nurse tries to determine why the outcome criteria and actual condition of skin do not agree.
3. The nurse inspects the condition of the skin.
4. The nurse reviews the outcome criteria to identify the desired skin condition.
5. The compares the degree of agreement between desired and actual condition of the skin.

Back 8

#1. The nurse reviews the outcome criteria to identify the desired skin condition.
#2. The nurse inspects the condition of the skin.
#3. The nurse compares the degree of agreement between desired and actual condition of the skin.
#4. The nurse judges the extent to which the condition of the skin matches the outcome criteria.
#5. The nurse tries to determine why the outcome criteria and actual condition of the skin do not agree.

Front 9

C9. The nurse checks the intravenous (IV) solution that is infusing into the pt's left arm. The IV solution of 9% NS is infusing at 100 mL/hr as ordered. The nurse reviews the nurse's 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. Check the IV infusion location in left arm
2. Checked the type of IV solution.
3. Confirmed from nurse's notes the time of dressing change and checked label
4. Inspected the condition of the IV dressing.

Back 9

3. and 4.

Front 10

C10. Which of the following statements correctly describe the evaluation process? (Select all that apply)

1. Eval is an ongoing proces.
2. Eval usually reveals obvious changes in pts.
3. Evall involves making clinical decisions.
4. Eval requires the use of assessment skills.

Back 10

1., 3., 4.

Front 11

C11. A clinic nurse assesses a pt who reports a loss of appetite and a 15 pound weight loss since 2 months ago. The pt is 5 ft 10 inches tall and weighs 135 lbs. She shows signs of depression and does not have a good understanding of foods to eat for proper nutrition. The nurse makes the nursing diagnosis of "imbalanced nutrition: less than body requirements related to reduced food intake." For the goal of, "Pt will return to baseline weight in 3 months" which of the following outcomes would be appropriate? (Select all that apply)

1. Pt will discuss source of depression by next clinic visit.
2. Pt will achieve a calorie intake of 2400 daily in 2 weeks.
3. Pt will report improvement in appetite in 1 week.
4. Pt will identify food protein sources.

Back 11

2. & 3.

Front 12

C12. A pt is being discharged after abdominal surgery. The abdominal incision is healing well with no signs of redness or irritation. Following instruction, the pt has demonstrated effective care of the incision, including cleansing the wound and applying dressings correctly to the nurse. These behaviors are an example of:

1. Evaluative measure.
2. Expected outcome
3. Reassessment
4. Standard of care.

Back 12

2. Expected outcome

Front 13

C13. A pt has limited mobility as a result of a recent knee replacement. The nurse identifies that he has altered balance and assists him in ambulation. The pt uses a walker presently as part of his therapy. The nurse notes how far the pt is able to walk and then assists him back to his room. Which of the following is an evaluative measure?
1. Uses walker during ambulation
2. Presence of altered balance
3. Limited mobility in lower extremities
4. Observation of distance patient is able to walk.

Back 13

4. Observation of distance pt is able to walk.

Front 14

C14. A pt is being discharged today. In preparation the nurse removes the intravenous (IV) line from the right arm and documents that the site was "clean and dry with no signs of redness or tenderness." On discharge the nurse reviews the care plan for goals met. Which of the following goals can be evaluated with what you know about this pt?

1. Pt expresses acceptance of health status by day of discharge.
2. Pt's surgical wound will remain free of infection.
3. Pt's IV site will remain free of phlebitis.
4. Pt understands when to call physician to report possible complications.

Back 14

3. Pt's IV site will remain free of phlebitis

Front 15

C15. 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. A nursing-sensitive outcome suitable for this diagnosis would be:

1. Pt will achieve pain relief by discharge.
2. Pt will be free of a surgical wound infection by discharge.
3. Pt will report reduced pain severity in 2 days.
4. Pt will describe purpose of pain medicine by discharge.

Back 15

Pt will report reduced pain severity in 2 days.

Front 16

W1. Briefly define the final step of the NP.

Back 16

Evaluation is done after the application of the nursing process and the pt's condition or well-being improves.

Front 17

W2. The purpose of conducting evaluative measures is ?

Back 17

To determine if you met the expected outcomes, not if the nursing interventions were completed.

Front 18

W3. The competencies for evaluation are: (4 things)

Back 18

1. Being systematic and using criterion-based evaluation
2. Collaborating with pts and other professionals
3. Using ongoing assessment data to revise the plan
4. Communicate the results to pts and family.

Front 19

W4. Explain Criterion-based evaluation.

Back 19

You evaluate nursing care by knowing what to look for based on standards included in a pt's goals and expected outcomes.

Front 20

W5a. Explain "Goals."

Back 20

States the expected behavior or response that indicates resolution of a nursing Dx or maintenance of a healthy state.

Front 21

W5b. Explain "Expected Outcomes."

Back 21

Describe an end result that is measurable, desirable, and observable and translates into observable patient behaviors.

Front 22

W5c. Nursing-sensitive pt outcome

Back 22

Evaluative measures gauge the pt or family state, behavior, or perception largely influenced by and sensitive to nursing interventions.

Front 23

W6. Explain the purpose of the Nursing Outcomes Classification (NOC).

Back 23

NOC identifies, labels, validates, and classifies nurse-sensitive patient outcomes. Its purpose is to field test and validate the classification and to define and test measurement procedures for the outcomes and indicators using clinical data.

Front 24

W7a. What's the intent of an "Assessment" measure.

W7b. What's the intent of an "Evaluative" measure.

Back 24

a. The intent of an assessment is to identify what, if any, problems exist.

b. The intent of evaluation is to determine if the known problems have remained the same, improved, worsened, or changed.

Front 25

W8. List the steps to evaluate the degree of success in achieving the outcomes of care.

Back 25

1. Examine the outcome criteria to identify the exact desired patient behavior.
2. Assess the pt's actual behavior or response.
3. Compare the established outcome criteria with the actual behavior.
4. Judge the degree of agreement between outcome criteria and the actual behavior.
5. If there is no agreement between the outcome criteria and the actual behavior, what are the barriers?

Front 26

W9. ID the responsibilities of documenting and reporting.

Back 26

The nurse is responsible for consistent, thorough documentation of the pt's progress toward the expected outcomes and use of nursing diagnostic language. When documenting a pt's response to the interventions, the nurse should describe the intervention, the evaluative measures used, the outcomes achieved, and the continued plan of care.

Front 27

W10. Explain Care plan revision.

Back 27

Each time the nurse evaluates a pt, he/she determines if the care plan continues or if revisions are necessary. The nurse may have to modify or add Nursing Dx with appropriate goals, expected outcomes, and interventions.

Front 28

W11. Explain Discontinuing a care plan.

Back 28

If the nurse and the pt agree that the expected outcomes and goals have been met, then that portion of the care plan is discontinued.

Front 29

W12. Explain Modifying a care plan.

Back 29

ID the factors interfering with goal achievement.

Front 30

W13. Explain Goals and Expected Outcomes.

Back 30

Determine if the goals were appropriate, realistic, and time appropriate.

Front 31

W14. Explain Interventions.

Back 31

Determine the appropriateness of the interventions (standards of care) selected and the correct application of the intervention.

Front 32

W15. Measuring the pt's response to nursing interventions and his or her progress toward achieving goals occurs during which phase of the nursing process?

1. Planning
2. Evaluation
3. Assessment
4. Nursing Dx

Back 32

2. Determines whether pt's condition or well-being has improved after the application of the nursing process.

Front 33

W16. Evaluation is:
1. Only necessary if the health care provider orders it.
2. An integrated, ongoing nursing care activity.
3. Begun immediately before the pt's discharge.
4. Performed primarily by nurses in the quality assurance department

Back 33

2. Whenever you have contact with a pt, you continually make clinical decisions and redirect nursing care; this is an ongoing process.

Front 34

W17. The criteria used to determine the effectiveness of a nursing action are based on the:

1. Nursing diagnosis
2. Expected outcomes
3. Pt's satisfaction
4. Nursing interventions

Back 34

2. They are the expected favorable and measurable results of nursing care.

Front 35

W18. When a pt-centered goal has not been met in the projected time frame, the most appropriate action by the nurse would be to:

1. Rewrite the plan using different interventions.
2. Continue with the same plan until the goal is met.
3. Repeat the entire sequence of the nursing process to discover needed changes.
4. Conclude that the goal was inappropriate or unrealistic and eliminate it from the plan.

Back 35

3. If the goals have not been met, you may need to adjust the plan of care by the use of interventions, modify or add nursing diagnoses with appropriate goals and expected outcomes, and redefine priorities.