Review Practice Exercise 3

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Practice Exercise 3

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Total Questions : 4

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Question 1:

A nurse is documenting evaluation findings. Which of the following is the correct example of an evaluative statement?

A. “Outcome not met.” B. “1/21/09—Client reports no change in tobacco use.” C. “Outcome not met. Client reports no change in tobacco use.” D. “1/21/09—Outcome not met. Client reports no change in tobacco use.”

Answer and Explanation

Choice A:

Outcome not met is incorrect because it lacks the date and supporting evaluative evidence. Stating only the outcome status fails legal documentation standards and does not provide clinical justification for why the goal was not achieved.

Choice B:

1/21/09-Client reports no change in tobacco use is incorrect because it provides data without documenting a formal evaluative judgment. Clinical data alone fails to state whether the outcome was met, partially met, or unmet.

Choice C:

Outcome not met. Client reports no change in tobacco use is incorrect because it lacks a date stamp. Omitting entry dates violates fundamental legal documentation guidelines required for medical records.

Choice D:

1/21/09-Outcome not met. Client reports no change in tobacco use is correct because it includes the date, a clear judgment on goal attainment, and specific evaluative data to support the conclusion. Complete documentation ensures accountability, legal compliance, and clear interprofessional communication regarding client care outcomes.

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Question 2:

A nurse is assessing the purposes of the evaluation phase in the nursing process. Which of the following accurately describes the purposes of evaluation? Select all that apply

A. Determine client progress toward achievement of expected outcomes. B. Determine effectiveness of nursing care. C. Establish client expected outcomes. D. Establish priorities for nursing interventions. E. Promote nursing accountability. F. Write the plan of care, including specific measurable goals.

Answer and Explanation

Choice A:

Determining client progress toward achievement of expected outcomes is a primary objective of evaluation. The nurse systematically compares post-intervention physiological and behavioral patient data against established baseline indicators. This continuous assessment verifies whether clinical goals are met, partially met, or unmet.

Choice B:

Determining effectiveness of nursing care reflects the core evaluative purpose within clinical practice. The nurse analyzes whether targeted therapeutic interventions successfully produced desired health responses or resolved nursing diagnoses. This appraisal guides necessary modifications, continuation, or total revision of clinical care plans.

Choice C:

Establishing client expected outcomes occurs during the planning phase of the nursing process rather than evaluation. During planning, the nurse formulates specific, measurable, short-term, and long-term goal criteria based on identified nursing diagnoses. Evaluation subsequently measures progress against these predetermined metrics later. It does not initially create them.

Choice D:

Establishing priorities for nursing interventions is an integral component of the planning step. Nurses prioritize patient needs using clinical frameworks such as Maslow's hierarchy and acute physiological urgency. This prioritization organizes therapeutic actions before implementation occurs in practice. Evaluation subsequently analyzes the outcomes of those prioritized actions.

Choice E:

Promoting nursing accountability represents a fundamental professional purpose of the evaluation step. Systematic outcome measurement holds clinicians responsible for delivering evidence-based interventions and meeting established standards of practice. It ensures quality healthcare delivery and justifies professional nursing clinical decision-making.

Choice F:

Writing the plan of care, including specific measurable goals is completed in the planning phase. Documenting target goals and prescribing individualized nursing activities establishes the clinical blueprint before implementation. Evaluation occurs after implementation to judge goal achievement and plan efficacy. It does not draft the initial plan.

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Question 3:

A nurse is caring for a client with acute pain. In which of the following situations is the nurse performing evaluation?

A. Determining a client’s baseline temperature B. Developing expected client outcomes C. Asking a client if pain is relieved after administration of analgesics D. Writing an individualized plan of care for a client

Answer and Explanation

Choice A:

Determining a client’s baseline temperature represents the assessment phase of the nursing process. Assessment involves systematically gathering, verifying, and documenting primary clinical data, such as vital signs, before implementing care. Baseline data collection identifies patient needs but does not measure the outcome of a specific intervention.

Choice B:

Developing expected client outcomes is an essential step within the planning phase of the nursing process. During planning, the nurse formulates measurable, short-term, and long-term goals that serve as benchmarks for future evaluation. Establishing goals occurs prior to performing interventions, making it distinct from measuring their actual results.

Choice C:

Asking a client if pain is relieved after administration of analgesics accurately reflects the evaluation step of the nursing process. Evaluation assesses the clinical effectiveness of a previously implemented nursing intervention. By obtaining a post-analgesic pain rating, the nurse measures whether the medication successfully achieved the desired therapeutic effect.

Choice D:

Writing an individualized plan of care for a client is completed during the planning phase. Documenting nursing diagnoses, client goals, and prescribed nursing actions creates the structural roadmap for delivery of care. Writing the plan prepares the nurse for implementation and precedes the evaluative measurement of care outcomes.

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Question 4:

A nurse enters a client’s room and begins a conversation. During this time the nurse evaluates how a client is tolerating a new diet plan. The nurse decides to also evaluate the client’s expectations of care. Which of the following is appropriate for evaluating a client’s expectations of care?

A. On a scale of 0 to 10 rate your level of nausea. B. The nurse weighs the client. C. The nurse asks, “Do you believe that you received the information you needed to follow your diet?” D. The nurse states, “Tell me four different foods included in your diet.”

Answer and Explanation

Choice A:

Asking the client, "On a scale of 0 to 10 rate your level of nausea," is an evaluation of physical symptom severity rather than care expectations. Rating nausea on a numerical scale gathers quantitative clinical data regarding gastrointestinal tolerance to the new diet. It measures physiological response rather than the client's perception of care quality.

Choice B:

The nurse weighing the client is an objective physical evaluation of nutritional status and fluid balance. Obtaining a physical weight provides measurable physiological data to determine whether the diet plan is achieving weight management goals. Physical measurements do not measure subjective expectations of care.

Choice C:

Asking, “Do you believe that you received the information you needed to follow your diet?” is an appropriate measure for evaluating a client's expectations of care. Evaluating expectations focuses on assessing whether the client feels their informational needs, care goals, and personal preferences were adequately met by the healthcare team. Eliciting client feedback regarding information delivery measures satisfaction with care delivery.

Choice D:

The statement, “Tell me four different foods included in your diet,” evaluates cognitive learning comprehension rather than expectations of care. Directing the client to list permitted food items assesses retention of dietary education. Verifying knowledge evaluates educational outcomes rather than client satisfaction with care delivery.

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Practice Exercise 3

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