A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." One of the following statements demonstrates that the nurse appropriately evaluated this goal.
Outcome not met. The client is able to state one positive aspect by the end of the week.
Outcome met. The client is able to state two positive aspects of therapy by week's end.
Outcome incomplete. The client is not able to positively state anything about rehab.
Outcome met. The client is able to state one positive aspect by the end of the week.
The Correct Answer is B
This statement demonstrates that the nurse appropriately evaluated the goal because it shows that the client was able to meet the goal of stating two positive aspects of rehab therapy by the end of the week. The other statements indicate that the outcome was either not met, incomplete, or only partially met.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nursing process consists of five phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, the nurse gathers information about the client's health status and needs. In this scenario, the nurse is conducting a dressing change and notes a new area of skin breakdown. This observation is part of the assessment phase of the nursing process, as the nurse is gathering information about the client's condition. The other phases of the nursing process involve analyzing the information gathered during assessment (diagnosis), developing a plan of care (planning), carrying out interventions (implementation), and evaluating the effectiveness of care (evaluation).
Correct Answer is D
Explanation
The nurse should immediately report a respiratory rate of 8 to the physician. A normal respiratory rate for an adult is between 12 and 20 breaths per minute. A respiratory rate of 8 is considered abnormally low and can indicate respiratory depression, which can be a side effect of pain medication delivered through an epidural catheter. It is important for the nurse to report this finding immediately so that appropriate interventions can be taken to ensure the safety of the client.
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