The following statement appears on the nursing care plan for an immune suppressed client. The client will remain free from infection throughout hospitalization. This statement is an example of a (an)?

1. A

   Nursing diagnosis

2. B

   Short-term goal

3. C

   Long-term goal

4. D

   Expected outcome

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

• An expected outcome is a specific, measurable statement of patient behavior or physiological response that is used to evaluate the effectiveness of nursing interventions.
• The statement "The client will remain free from infection throughout hospitalization" meets the criteria for an expected outcome: it is specific (no infection), measurable (absence of signs like fever, high WBC count), and has a defined time frame (during hospitalization).
• Unlike broader goals, expected outcomes provide the precise criteria needed for the evaluation phase of the nursing process.
• According to the SMART acronym, a well-written outcome is Specific, Measurable, Attainable, Realistic, and Timed.

Why Other Options Were Wrong

• Option A: A nursing diagnosis is a statement of a patient's health problem that a nurse can treat. It identifies the problem, not the desired resolution.
• Option B: While preventing infection is a goal, 'short-term' is too specific and may be inaccurate. Hospitalization can last for weeks, which would not be considered short-term.
• Option C: Similar to a short-term goal, this term is less precise than 'expected outcome.' A hospitalization might only be for a few days, which would not be considered long-term.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Components of a Nursing Care Plan to guide bedside assessment, documentation, and the next nursing action.
• For an immunosuppressed client, preventing infection is a paramount nursing priority. Clearly defined outcomes are essential to guide and evaluate the effectiveness of protective measures.
• Nursing interventions to achieve this outcome include implementing neutropenic precautions, strict hand hygiene, continuous monitoring for early signs of infection (even subtle ones like a low-grade fever), and patient education.
• What if? If the statement was 'The client will demonstrate correct hand hygiene technique,' this would be a behavioral outcome, which is a type of expected outcome focused on the patient's actions rather than their physiological state.

How to Approach the Question

• First, identify the core task: you need to classify the given statement according to the steps of the nursing process.
• Analyze the statement: 'The client will remain free from infection throughout hospitalization.' Note that it is patient-centered, describes a desired condition ('free from infection'), and includes a time frame ('throughout hospitalization').
• Evaluate each option. A 'nursing diagnosis' is a problem statement (e.g., 'Risk for Infection'), so eliminate that choice.
• Differentiate between 'goal' and 'outcome.' A goal is a broad aim, while an outcome is the specific, measurable criterion used to evaluate if the goal was met. The statement is very specific and measurable.
• Consider the time frames. 'Short-term' and 'long-term' are relative and depend on the length of hospitalization, making them less precise. 'Expected outcome' is the most accurate term because it focuses on the measurable result, regardless of the exact time frame.
• Conclude that 'Expected outcome' is the best fit as it is a specific, measurable standard for evaluating care.

Concept Tested & Keywords

• Concept Tested: Components of a Nursing Care Plan
• Stem keywords: nursing care plan, immune suppressed client, remain free from infection, throughout hospitalization
• Lead-in keywords: example of
• Clinical cues: The client is immunosuppressed, which makes infection prevention a high-priority.

Question ID

QU68Tuz9_RTCS9JOdnPJk6

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 2 pp. 25-27, 23-25

E6 Nursing Fundamentals Taylor p. 449-451