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Chapter 020

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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 20: Evaluation MULTIPLE CHOICE 1. The client smokes two packs of cigarettes per day. The nurse works with the client, and they agree that he will smoke one cigarette less each week until he is down to one pack per day. In 3 weeks, the client is smoking two and a half packs of cigarettes per day. This is an example of: 1. A realistic goal 2. A compliant client 3. A negative evaluation 4. A nonmeasurable goal ANS: 3 This is an
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 2: E!aluation #$T%P$E C'%CE 1.The client smokes two packs of cigarettes per day. The nurse works with the client, and they agree that he will smoke one cigarette less each week until he is down to one pack  per day. In 3 weeks, the client is smoking two and a half packs of cigarettes per day. This is an example of:1.A realistic goal2.A compliant client3.A negatie ealuation!.A nonmeasura le goalA#$:3This is an example of a negatie ealuation. %uring ealuation, the nurse is a le to determine that the client has not met the expected outcome of decreasing smoking y onecigarette each week ut rather has increased his smoking. This is not an example of a realistic goal. It is an example of the ealuation step of the nursing process. The client is noncompliant. The goal is measura le. %uring ealuation, the nurse determines if expected outcomes are met in order to &udge if goals hae een met.%I':A()':2*1+-:omprehensionT+/:#ursing /rocess: )aluation0$:#) test plan designation: $afe, )ffectie are )nironment2.The nurse formulates a diagnosis of knowledge deficit related to complications of  pregnancy . +ne outcome criterion is that the client can state fie symptoms that indicate a possi le pro lem that should e reported. The client is a le to tell the nurse three symptoms. The ealuation statement would e:1.4oal met5 client a le to state three symptoms2.4oal not met5 client a le to list three symptoms3.4oal not met5 client una le to list fie symptoms !.4oal partially met5 client a le to state three symptomsA#$:!The client is showing changes ut does not yet meet criteria set5 therefore, the goal is  partially met. The client6s response, eing a le to state three symptoms, does not meet or exceed the outcome criteria of eing a le to state fie symptoms. The client6s response,   eing a le to list three symptoms, demonstrates some change. If the client were showing no progress, then the goal would not e met. If the client were showing no progress, then the goal would not e met. 7oweer, this client6s response does indicate some change.%I':A()':2*8+-:omprehensionT+/:#ursing /rocess: )aluation0$:#) test plan designation: $afe, )ffectie are )nironment 0os y items and deried items 9 2*, 2; y 0os y, Inc., an affiliate of )lseier Inc.  Test ank 3.The nurse egins to auscultate the client6s lungs. <hile listening, the nurse notices fresh   loody drainage oo=ing from the a dominal dressing. The nurse stops auscultating and applies direct pressure to the wound site. This is an example of:1./erforming a nursing assessment2.(eorgani=ing the nursing diagnoses3.Implementing nursing interentions!.ritically analy=ing client assessment dataA#$:!The nurse who stops auscultating lung sounds to take measures to stop noticea le   leeding is analy=ing data presented. This is demonstrated y the nurse setting priorities and effectiely implementing the safest nursing action. The nurse is doing more than  performing a nursing assessment. The nurse is taking action ased on new assessment data. The nurse is not reorgani=ing nursing diagnoses. The nurse is implementing the  priority nursing action. This is not an example of setting realistic goals and implementing nursing interentions. Applying direct pressure to a wound site to stop leeding demonstrates critical analysis of the data and implementation of the safest nursing action.%I':A()':2*>+-:omprehensionT+/:#ursing /rocess: )aluation0$:#) test plan designation: $afe, )ffectie are )nironment!.The client is a le to am ulate without signs or symptoms of shortness of reath. <hich statement y the nurse is the est example of an o &ectie ealuation of the client6s goal attainment?1.@lient has no pain after am ulating.2.@lient has no manifestations of nausea while up in hall.3.@lient walked well and did not hae any pro lem when up.!.@lient has no eidence of respiratory distress when am ulating.A#$:!@lient has no eidence of respiratory distress when am ulating is the est example of an o &ectie ealuation of the client6s goal attainment. It uses the same ealuatie measures gathered during assessment and clearly descri es o &ectie data. @lient has no  pain after am ulating does not use the same ealuatie measure gathered during assessment. The assessment measure concerned respiratory changes during am ulation, not pain. If the client6s pain leel were going to e used as an ealuatie measure, it would e optimal to hae the client report the pain using a pain scale to make it more measura le for comparison. @lient has no manifestations of nausea while up in hall is not the est example of an o &ectie ealuation of the client6s goal attainment. It does not use the same ealuatie measure gathered during assessment. The assessment measure concerned respiratory changes during am ulation, not nausea. Also, nausea is more su &ectie. @lient walked well and did not hae any pro lem when up is not the est example of an o &ectie ealuation. It includes the nurse6s interpretation rather than documentation of o &ectie data. 0os y items and deried items 9 2*, 2; y 0os y, Inc., an affiliate of )lseier Inc. 2B2  Test ank %I':A()':2*!+-:omprehensionT+/:#ursing /rocess: )aluation0$:#) test plan designation: $afe, )ffectie are )nironment;.<hen modifying a care plan to meet a client whose status has changed significantly oer the past few days, the nurse should:1.(edeelop the entire client care plan2.'ocus on changing the nursing diagnoses and goals3./erform a complete reassessment of all client factors!.Add more nursing interentions from a standardi=ed plan of careA#$:3A complete reassessment of all client factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. After reassessment the nurse will determinewhat components of the care plan are accurate for the situation. It may not reCuire redoing the entire care plan. The nurse should not only focus on the nursing diagnoses and goals that hae changed. Interentions may also need reising to meet new goals. Adding more nursing interentions may or may not e necessary. The nurse ad&usts interentions on the asis of the client6s response and preious experience with similar clients. $tandards of care are used to determine whether the right interentions hae een chosen or whether additional ones are reCuired.%I':A()':2*D+-:omprehensionT+/:#ursing /rocess: )aluation0$:#) test plan designation: $afe, )ffectie are )nironment8.ased on the following outcome criterion determined y the nurse: @lient will independently complete necessary assessments prior to administration of digoxin EcardiotonicF the nurse will ealuate the client6s a ility to:1.Assess the respiratory rate 2./alpate the radial pulse3.(eiew dietary ha its!.Inspect color of the skinA#$:2The nurse should compare the esta lished outcome criteria with the client6s ehaior or response. In this case the client is expected to independently complete the necessary assessments efore administration of digoxin. The client should e a le to palpate the radial pulse as an assessment efore administration of digoxin. The outcome criterion does not state anything a out exercise. %uring ealuation, the nurse is to &udge the degreeof agreement etween the outcome criteria and the client6s ehaior. The outcome criterion does not state anything a out diet. )aluating whether the client reiews dietary ha its would not e compara le to necessary assessment efore medication administration. The outcome criterion does not state anything a out the skin. The nurse, who knows that digoxin is a cardiotonic, understands that the client should e assessing the heart rate. 0os y items and deried items 9 2*, 2; y 0os y, Inc., an affiliate of )lseier Inc. 2B3  Test ank %I':A()':2*1+-:omprehensionT+/:#ursing /rocess: )aluation0$:#) test plan designation: $afe, )ffectie are )nironmentD.The nurse has determined the following outcome for a client with a skin impairment: @)rythema will e reduced in 3 days. )aluation will specifically focus on:1.$election of appropriate wound care2.#otation of the odor and color of drainage3.Inspection of the color and condition of the area!.0easurement of the diameter of the ulceration dailyA#$:3)rythema is reddening of the skin5 therefore, the ealuation should specifically focus on inspection of the color of the skin, as stated in the outcome criterion. $election of appropriate wound care is an interention, not an ealuation of a client6s ehaior or response. The outcome criterion does not state anything a out drainage. #oting the color and amount of drainage may e a part of reassessment of the client, ut is not what the nurse is ealuating according to this outcome criterion. The outcome criterion states the erythema will e reduced, not the si=e of the ulceration. %uring the ealuation step of the nursing process, the client6s ehaior or response should e compared to the outcome criterion and &udged for degree of agreement etween the two.%I':A()':2*!+-:omprehensionT+/:#ursing /rocess: )aluation0$:#) test plan designation: $afe, )ffectie are )nironment>.The client has a nursing diagnosis of impaired gas exchange  as a result of excessie secretions. An outcome for the client is that the airways will e free of secretions. A  positie ealuation will focus upon the client6s:1.(espiratory rate2.omplaint of chest pain 3.ungs clear ilaterally on auscultation!.A ility to perform incentie spirometryA#$:3Auscultating lung sounds is the est way to determine if airways are clear. A positie ealuation is that they are clear, as expected in the outcome statement. (espiratory rate may e an indicator of respiratory status, ut it is not the est way to determine if airwaysare free of secretions. A complaint of chest pain would e a negatie outcome, and it is not the focus for determining whether airways are free of secretions as written in the outcome statement. 7aing the a ility to perform incentie spirometry does not determine whether the airways are clear or not. It is an interention that may help achieeclear airways.%I':A()':2*!+-:omprehensionT+/:#ursing /rocess: )aluation0$:#) test plan designation: $afe, )ffectie are )nironment 0os y items and deried items 9 2*, 2; y 0os y, Inc., an affiliate of )lseier Inc. 2B!

Chapter 015

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Chapter 013

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