Chapter 19 Practice Questions
1. An older adult client has lost significant muscle mass during recovery from a
systemic infection. As a result, the client has made no progress toward meeting any
of the outcomes for mobility and activities of daily living that are specified in the
nursing plan of care. How should the nurse best respond to this situation?
A. Continue the current plan of care with the hope that the client will achieve the
outcomes.
B. Terminate the plan of care because it does not now accurately reflect the client's
abilities.
C. Modify the plan of care to better reflect the client's current functional ability.
D. Replace the client's individualized plan of care with a clinical pathway.
2. A nurse is evaluating an established plan of care. After identifying the evaluative
criteria and standards (expected patient outcomes), what must the nurse do next?
A. Interpret and summarize findings.
B. Document the nurse's judgment.
C. Collect data about client responses.
D. Formulate a new plan of care.
3. A nurse is evaluating the outcomes of a plan of care to teach a client with a BMI
of 33 about the calorie content of foods. What type of outcome is this?
A. psychomotor
B. affective
C. physiologic
D. cognitive
4. A nurse is educating a client on how to administer insulin, with the expected
outcome that the client will be able to self-administer the insulin injection. How
would the nurse evaluate this outcome?
A. Ask the client to verbally repeat the steps of the injection.
B. Ask the client to demonstrate self-injection of insulin.
C. Ask family members how much trouble the client is having with injections.
D. Ask the client how comfortable the client is with injections.
5. At the beginning of prenatal care, the goal for the client was to gain 25 lb (11.25
kg) by the end of the pregnancy. At 30 weeks of pregnancy, the client has only
gained 1 lb (0.45 kg). Which statement helps the nurse interpret these data
appropriately?
A. It is too early to evaluate if the goal has been achieved. The client has 10 more
weeks of pregnancy.
B. The client is not achieving the goal. The nurse should determine the reasons the
client has not been gaining weight.
C. The client is progressing toward achieving the goal. The plan should be
continued.
D. The client has partially achieved the determined goal. The nurse should revise
the goal to reflect a more realistic outcome.
6. Which activities does the nurse engage in during the evaluation phase? Select all
that apply.
A. Collects data to determine whether desired outcomes are met
B. Assesses the effectiveness of planned strategies
C. Adjusts the time frame to achieve the desired outcomes
D. Involves the client and family in formulating desired outcomes
E. Initiates activities to achieve the desired outcomes
7. The nurse is caring for the client with pneumonia. An expected client outcome is,
"The client will maintain adequate oxygenation by discharge." Which outcome
criterion indicates the goal is met?
A. Client drinks at least 2 to 3 liters of water each day.
B. Client completes coughing and deep breathing exercises hourly.
C. Client does not demonstrate signs of orthostatic hypotension when ambulating.
D. Client no longer requires supplemental oxygen.
8. A nurse is a member of a group involved in a quality assurance program. The
group is involved in a process evaluation. On which area will the group focus?
A. performance of nursing interventions
B. hierarchy of the organizational structure
C. financial resources
D. changes in clients' health status
9. A nurse is evaluating the outcomes identified on the plan of care for first-time
parents of a newborn. Which evaluative statement addresses a cognitive outcome?
A. 2/6: Outcome met. Parents able to verbalize common problems associated with
newborn feeding and appropriate strategies to address them.
B. 2/6: Outcome met. Both parents state that they are comfortable and ready to
care for their newborn.
C. 2/6: Outcome partially met. Mother demonstrated ability to diaper newborn
correctly; father still requiring consistent prompting related to steps throughout
diaper application.
D. 2/6: Both parents reported feeling able to cope with the role changes associated
with having a newborn.
10. A nurse manager is engaged in a formal evaluation of their own performance as
a means of improvement. Which individual is best to provide this feedback to the
nurse manager?
A. another nurse manager
B. director of nursing
C. staff nurse on the unit
D. nursing shift supervisor