Chapter 19: Evaluation Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

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:

a.

A realistic goal

b.

A compliant client

c.

A negative evaluation

d.

A nonmeasurable goal

ANS: c

c. This is an example of a negative evaluation. During evaluation, the nurse is able to determine that the client has not met the expected outcome of decreasing smoking by one cigarette each week, but rather has increased his smoking.

a. This is not an example of a realistic goal. It is an example of the evaluation step of the nursing process.

b. The client is noncompliant.

d. The goal is measurable. During evaluation, the nurse determines whether expected outcomes are met to judge if certain goals have been met

REF: Text Reference: p. 361

2. The client is seen in the clinic for her first prenatal visit. The nurse formulates a diagnosis of Knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. The evaluation statement would be:

a.

Goal met; client able to state three symptoms

b.

Goal partially met; client able to state three symptoms

c.

Goal not met; client unable to list five symptoms

d.

Goal not met; client able to list three symptoms

ANS: b

b. The client is showing changes but does not yet meet criteria set; therefore, the goal is partially met.

a. The clients response, being able to state three symptoms, does not meet or exceed the outcome criterion of being able to state five symptoms.

c. If the client were showing no progress, then the goal would be not met. However, this clients response does indicate some change.

d. The clients response, being able to list three symptoms, demonstrates some change. If the client were showing no progress, then the goal would be not met.

REF: Text Reference: p. 362

3. The nurse begins to auscultate the clients lungs. While listening, the nurse notices fresh bloody drainage oozing from the abdominal dressing. The nurse stops auscultating and applies direct pressure to the wound site. This is an example of:

a.

Performing a nursing assessment

b.

Reorganizing the nursing diagnoses

c.

Setting realistic goals and implementing nursing interventions

d.

Critically analyzing the data and effectively implementing the safest nursing action

ANS: d

d. The nurse who stops auscultating lung sounds to take measures to stop noticeable bleeding is analyzing data presented, as demonstrated by the nurse setting priorities, and is effectively implementing the safest nursing action.

a. The nurse is doing more than performing a nursing assessment. The nurse is taking action based on new assessment data.

b. The nurse is not reorganizing nursing diagnoses. The nurse is implementing the priority nursing action.

c. This is not an example of setting realistic goals and implementing nursing interventions. Applying direct pressure to a wound site to stop bleeding demonstrates critical analysis of the data and implementation of the safest nursing action.

REF: Text Reference: p. 365

4. The client is able to ambulate without signs or symptoms of shortness of breath. Which statement by the nurse is the best example of an objective evaluation of the clients goal attainment?

a.

Client has no pain after ambulating.

b.

Client has no manifestations of nausea while up in hall.

c.

Client has no evidence of respiratory distress when ambulating.

d.

Client walked well and did not have any problem when up.

ANS: c

c. This is the best example of an objective evaluation of the clients goal attainment. It uses the same evaluative measures gathered during assessment and clearly describes objective data.

a. This statement does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not pain. If the clients pain level were going to be used as an evaluative measure, it would be optimal to have the client report the pain by using a pain scale to make it more measurable for comparison.

b. This statement is not the best example of an objective evaluation of the clients goal attainment. It does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not nausea. Nausea also is more subjective.

d. This is not the best example of an objective evaluation. It includes the nurses interpretation rather than documentation of objective data.

REF: Text Reference: p. 362

5. The clients status has changed significantly over the past few days. The nurse recognizes the need to update the plan of care. When modifying a care plan to meet a clients changing needs, the nurse should:

a.

Re-do the entire care plan.

b.

Focus only on the nursing diagnoses and goals that have changed.

c.

Perform a complete reassessment of all client factors

d.

Add more nursing interventions from a standardized plan of care.

ANS: c

c. A complete reassessment of all client factors relating to the nursing diagnosis and etiology is necessary when modifying a plan.

a. After reassessment. the nurse will determine what components of the care plan are accurate for the situation. It may not require re-doing the entire care plan.

b. The nurse should focus not only on the nursing diagnoses and goals that have changed. Interventions may also need revising to meet new goals.

d. Adding more nursing interventions may or may not be necessary. The nurse adjusts interventions on the basis of the clients response and previous experience with similar clients. Standards of care are used to determine whether the right interventions have been chosen or whether additional ones are required.

REF: Text Reference: p. 363

6. The nurse has determined an outcome criterion of: client will independently complete necessary assessments before administration of digoxin (cardiotonic). Based on this outcome, the nurse will evaluate the clients ability to:

a.

Assess the respiratory rate during exercise

b.

Palpate the radial pulse

c.

Review dietary habits

d.

Inspect the color of the skin

ANS: b

b. The nurse should compare the established outcome criteria with the clients behavior or response. In this case, the client is expected to complete independently the necessary assessments before administration of digoxin. The client should be able to palpate the radial pulse as an assessment prior to administration of digoxin.

a. The outcome criterion does not state anything about exercise. During evaluation, the nurse is to judge the degree of agreement between the outcome criterion and the clients behavior.

c. The outcome criterion does not state anything about diet. Evaluating whether the client reviews dietary habits would not be comparable to necessary assessment before medication administration.

d. The outcome criterion does not state anything about the skin. The nurse, who knows that digoxin is a cardiotonic, knows the client should be assessing the heart rate.

REF: Text Reference: p. 361

7. The nurse has determined an outcome for a client with a skin impairment that identifies: Erythema will be reduced in 3 days. Evaluation will specifically focus on:

a.

Measurement of the diameter of the ulceration daily

b.

Notation of the odor and color of drainage

c.

Inspection of the color and condition of the area

d.

Selection of appropriate wound care

ANS: c

c. Erythema is reddening of the skin; therefore, the evaluation should specifically focus on inspection of the color of the skin, as stated in the outcome criterion.

a. The outcome criterion states that the erythema will reduce, not the size of the ulceration. During the evaluation step of the nursing process, the clients behavior or response should be compared with the outcome criterion and judged for degree of agreement between the two.

b. The outcome criterion does not state anything about drainage. Noting the color and amount of drainage may be a part of reassessment of the client but is not what the nurse is evaluating according to this outcome criterion.

d. Selection of appropriate wound care is an intervention, not an evaluation of a clients behavior or response.

REF: Text Reference: p. 361

8. The client has a nursing diagnosis of Impaired gas exchange as a result of excess secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus on the clients:

a.

Ability to perform incentive spirometry

b.

Lungs clear bilaterally on auscultation

c.

Complaint of chest pain

d.

Respiratory rate

ANS: b

b. Auscultating lung sounds is the best way to determine whether airways are clear. A positive evaluation is that they are clear, as expected in the outcome statement.

a. Having the ability to perform incentive spirometry does not determine whether the airways are clear. It is an intervention that may help achieve clear airways.

c. A complaint of chest pain would be a negative outcome, and it is not the focus for determining whether airways are free of secretions, as written in the outcome statement.

d. Respiratory rate may be an indicator of respiratory status, but it is not the best way to determine whether airways are free of secretions.

REF: Text Reference: p. 361

Copyright 2005 by Mosby, Inc. All rights reserved.

Leave a Reply