Chapter20 Flashcards
You may measure or observe patient data in the same way during
assessment and evaluation
Evaluation
Determines whether a patient’s condition or well-being improved after nursing interventions were delivered
Are made following nursing intervention when you make decisions about a patient status and progress
evaluative measure
- Your patient has met the goals set for improvement of ambulatory status. You would now
A. modify the care plan.
B. discontinue the care plan.
C. create a new nursing diagnosis that states goals have been met.
D. reassess the patient’s response to care and evaluate the implementation step of
the nursing process.
B
Modifying a care plan
Redefining diagnoses
Revising goals and expected outcomes
Revising interventions
5-Name three things that need to be included in the documentation of outcomes:
describe the interventions,
the evaluative measures used,
the outcomes achieved,
the continued plan of care.
You have finished with several nursing interventions. To
aluate interventions, you need to examine the:
A. appropriateness of the interventions and the correct
application of the implementation process.
B. nursing diagnoses to ensure that they are not medical
diagnoses.
C. care planning process for errors in other health care
team members’
judgments.
D. interventions of each nurse to enable the nurse
manager to correctly evaluate performance.
A
A nurse admits a 32-year-old patient for treatment of acute
asthma. The patient has labored breathing, a respiratory rate of 28
per minute, and lung sounds with bilateral wheezing. The nurse
makes the patient comfortable and starts an ordered intravenous
infusion to administer medication that will relax the patient’s air-
ways. The patient tells the nurse after the first medication infu-
sion, “I feel as if I can breathe better? The nurse auscultates the
patient’s lungs and notes decreased wheezing with a respiratory
rate of 22 per minute. Which of the following is an evaluative
measure? (Select all that apply.)
- Asking patient to breathe deeply during auscultation
- Counting respirations per minute
- Asking the patient to describe how his breathing feels
- Starting the intravenous infusion
- Auscultating lung sounds
2
3
5
Which of the following statements correctly describes the evalua-
tion process? (Select all that apply.)
1. Evaluation involves reflection on the approach to care.
2. Evaluation involves determination of the completion of a nurs-
ing intervention.
3. Evaluation involves making clinical decisions.
4. Evaluation requires the use of assessment skills.
5. Evaluation is performed only when a patients condition
changes.
1
4
3
From the following list of indicators, determine which indicators
are goals (G) and which indicators are outcomes (O).
1__Will achieve pain relief
2.__Ambulates 10 feet down hallway
3__Will remain free of infection
4.__Will be afebrile
5.__Reports pain severity reduced from 6 to a 4 on scale of 0
to 10
6.__Will gain improved mobility
1G 2O 3G 4G 5O 6G
A nurse has been caring for a patient over 2 consecutive days.
During that time the patient had an intravenous (IV) catheter in
the right forearm. At the end of shift on the second day the nurse
inspects the catheter site, observes for redness, and asks whether
the patient feels tenderness when the site is palpated. The nurse
reviews the medical record from 24 hours ago and finds the cath-
eter site was without redness or tenderness. Which of the activi-
ties below reflect the nurse’s ability to perform patient evaluation?
(Select all that apply.)
1. Comparing patient response with previous response
2. Examining results of clinical data
3. Recognizing error
4. Self-reflection
5. Checking medical record for when IV was inserted.
1
2
Which of the following statements correctly describe the evalua.
tion process? (Select all that apply.)
1. Evaluation is an ongoing process.
2. Evaluation involves the gathering of data for recognizing errors
or omissions in care.
3. Evaluation involves making clinical decisions.
4. Evaluation requires the use of assessment skills.
5. Evaluation is done only when a patient’s condition changes.
1
2
3
4
