Chapter 20 Evaluation Flashcards
- A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his 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 of the following is an evaluative measure used by the nurse?
A. Suctioning the airway
B. Sitting patient up in bed
C. Auscultating lung sounds
D. Patient describing type of discomfort
C
Rationale:
Auscultation was the measure used to determine if the suctioning of the airway was effective. Suctioning and sitting the patient up are interventions. The nurse did not ask the patient or evaluate the nature of the pain.
- A 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 of the following would be appropriate evaluative criteria used by the nurse? (Select all that apply.)
A. Patient drinks contents of water glass.
B. Patient’s lungs are clear to auscultation in bases.
C. Patient reports abdominal pain on scale of 0 to 10.
D. Patient’s rate and depth of breathing are normal with head of bed elevated.
B and D
Rationale:
The criteria of clear lung sounds and rate and depth of breathing are evaluative criteria for determining if the patient’s airway is clear. Drinking the contents of the water glass is a completed intervention. The patient’s report of pain is assessment data.
- The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of interpretation?
A. Evaluating the patient’s response to selected nursing interventions
B. Selecting an observable or measurable state or behavior that reflects goal achievement
C. Reviewing the patient’s nursing diagnoses and establishing goals and outcome statements
D. Matching the results of evaluative measures with expected outcomes to determine patient’s status
D
Rationale:
When interpreting findings, you compare the patient’s behavioral responses and physiological signs and symptoms that you expect to see with those actually seen from your evaluation.
- A goal specifies the expected behavior or response that indicates:
A. The specific nursing action was completed.
B. The validation of the nurse’s physical assessment.
C. The nurse has made the correct nursing diagnoses.
D. Resolution of a nursing diagnosis or maintenance of a healthy state.
D
Rationale:
The success in meeting a goal is reflected in achieving expected outcomes—the physiological responses or behaviors that indicate that a nursing diagnosis has been resolved and the patient’s health is improving.
- A patient 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?
A. Patient will remain afebrile to discharge.
B. Patient’s wound will remain free of infection by discharge.
C. Patient will receive ordered antibiotic on time over next 3 days.
D. Patient’s abdominal incision will be covered with a sterile dressing for 2 days.
B
Rationale:
When selecting an at-risk diagnosis, the goal is to avoid or prevent the condition at risk, in this case infection. The statement “Patient will remain afebrile to discharge” is a potential outcome measure for the goal. The patient receiving an ordered antibiotic and having the abdominal incision covered are both interventions.
- Unmet and partially met goals require the nurse to do which of the following? (Select all that apply.)
A. Redefine priorities
B. Continue intervention
C. Discontinue care plan
D. Gather assessment data on a different nursing diagnosis
E. Compare the patient’s response with that of another patient
A and B
Rationale:
When you determine that a goal has not been met or has been met only partially, intervention must continue; and the fact that the health problem still exists suggests that priorities may need to be redefined. You do not discontinue a plan unless a goal has been achieved. Evaluation never involves comparing a patient’s data with that of another patient. A patient may develop new diagnoses at any time, but assessment of a new diagnosis does not address goals for an existing diagnosis.
- A patient comes to a medical 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 kg). Based on the nursing diagnosis of imbalanced nutrition: more than body requirements, the practitioner plans to place the patient on a therapeutic diet. Which of the following are evaluative measures for determining if the patient achieves the goal of a desired weight loss? (Select all that apply.)
A. The patient eats 2000 calories a day.
B. The patient is weighed during each clinic visit.
C. The patient discusses factors that increase the risk of an asthma attack.
D. The patient’s food diary that tracks intake of daily meals is reviewed.
B and D
Rationale:
Weighing the patient during each clinic visit and reviewing a food diary indicate whether weight loss is occurring and if the patient is eating the proper foods designed to reduce his or her weight.
- The nurse checks the intravenous (IV) solution that is infusing into the patient’s left arm. The IV solution of 9% 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.)
A. Checked the IV infusion location in left arm
B. Checked the type of IV solution
C. Confirmed from nurses’ notes the time of dressing change and checked label
D. Inspected the condition of the IV dressing
C and D
Rationale:
The evaluation of interventions examines two factors: the appropriateness of the interventions selected (whether the IV dressing was changed as the standard of care requires) and the correct application of the intervention (whether the dressing was in place and secure). Checking the IV infusion location in the left arm is an evaluation measure, and checking the type of IV solution is an assessment step to ensure that correct fluid is infusing.
- Which of the following statements correctly describe the evaluation process? (Select all that apply.)
A. Evaluation is an ongoing process.
B. Evaluation usually reveals obvious changes in patients.
C. Evaluation involves making clinical decisions.
D. Evaluation requires the use of assessment skills.
A C and D
Rationale:
Evaluation often reveals changes that are not obvious. Changes are often subtle and occur over a period of time.
- A clinic nurse assesses a patient who reports a loss of appetite and a 15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall and weighs 135 pounds (61.2 kg). 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 intake of food. For the goal of, “Patient will return to baseline weight in 3 months,” which of the following outcomes would be appropriate? (Select all that apply.)
A. Patient will discuss source of depression by next clinic visit.
B. Patient will achieve a calorie intake of 2400 daily in 2 weeks.
C. Patient will report improvement in appetite in 1 week.
D. Patient will identify food protein sources.
B and C
Rationale:
With the related factor of reduced intake of food, the outcomes should focus on behaviors that reflect an increase in intake. Thus achieving an increase in calories and an improved appetite for food would be appropriate. The patient’s depression probably contributes to the loss of appetite, but being able to discuss the source of depression is not an outcome for improving her baseline weight. Being able to identify protein sources would improve any knowledge deficit the patient might have but would not help her gain weight.
- A patient is being discharged after abdominal surgery. The abdominal incision is healing well with no signs of redness or irritation. Following instruction, the patient has demonstrated effective care of the incision, including cleansing the wound and applying dressings correctly to the nurse. These behaviors are an example of:
A. Evaluative measure.
B. Expected outcome.
C. Reassessment.
D. Standard of care.
B
Rationale:
An expected outcome is an end result that is measureable, desirable, observable, and translates into observable patient behaviors. It is a measure that tells you if the educational interventions led to successful goal achievement, the patient’s self-care of the wound. An evaluative measure would be the process of observing the patient. Reassessment is a behavior performed by the nurse. The type of wound cleanser and dressings would be a standard of care.
- A patient 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 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 of the following is an evaluative measure?
A. Uses walker during ambulation
B. Presence of altered balance
C. Limited mobility in lower extremities
D. Observation of distance patient is able to walk
D
Rationale:
An evaluative measure determines a patient’s response to therapy, in this case how well the patient is able to ambulate (distance walked).
- A patient 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 patient?
A. Patient expresses acceptance of health status by day of discharge.
B. Patient’s surgical wound will remain free of infection.
C. Patient’s IV site will remain free of phlebitis.
D. Patient understands when to call physician to report possible complications.
C
Rationale:
To achieve the goal of preventing phlebitis the nurse evaluates for signs of phlebitis, which include redness or inflammation. The outcome for this goal would be stated as, “IV site will show no signs of inflammation to discharge.”
- 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:
A. Patient will achieve pain relief by discharge.
B. Patient will be free of a surgical wound infection by discharge.
C. Patient will report reduced pain severity in 2 days.
D. Patient will describe purpose of pain medicine by discharge.
C
Rationale:
An example of a nursing-sensitive outcome is one that is influenced and sensitive to nursing interventions. Such is the case with “reduction in pain severity.” The patient achieving pain relief by discharge is a goal. The patient being free of a surgical wound infection by discharge is a medical outcome. The patient describing the purpose of pain medication by discharge is an outcome for a knowledge problem but not for the diagnosis of acute pain.
