A client presents to the clinic complaining of difficulty sleeping.
Which asks by the nurse are considered therapeutic in this scenario? Select all that apply.

Choice A rationale

Falsifying documentation is a severe ethical and legal violation that directly undermines patient safety and professional integrity. When a nurse records that a treatment was completed when it was not, it creates a false medical record that can lead to inappropriate clinical decisions by the rest of the healthcare team. This act of dishonesty is considered professional misconduct and typically warrants immediate disciplinary action by the licensing board and the employing institution.

Choice B rationale

While taking an extended lunch break may be a performance or productivity issue, it is generally handled through internal human resources policies or verbal warnings rather than formal disciplinary action by a nurse manager. This behavior does not necessarily constitute a clinical safety risk or a violation of the nursing practice act in the same way that clinical negligence or falsification of records does. It is usually addressed through standard workplace time management protocols.

Choice C rationale

Leaving unused supplies in a room is a minor breach of efficiency or infection control standards but does not rise to the level of professional disciplinary action. While it may lead to waste or clutter, it is an easily corrected habit that is typically managed through simple feedback or coaching. It does not demonstrate a lack of competence or a willful intent to harm, nor does it violate the core ethical duties of nursing.

Choice D rationale

Failing to administer a critical medication when a patient is experiencing a hypertensive crisis, defined as a blood pressure > 180/120 mmHg, represents a significant failure in clinical judgment and a breach of the standard of care. This omission can lead to life-threatening complications such as stroke or organ failure. Normal blood pressure is < 120/80 mmHg. Neglecting such an extreme reading requires formal investigation and potentially severe disciplinary consequences to ensure safety.

Choice E rationale

Patients have the legal and ethical right to refuse medical treatment or medications under the principle of autonomy. If a nurse respects a patient's refusal, documents it correctly, and notifies the provider, they are practicing within their professional scope. This action is not a cause for disciplinary measures because the nurse is upholding the rights of the individual. It is the nurse's responsibility to educate the patient, but they cannot force compliance.

Choice A rationale

This goal is incorrectly written because it lacks a specific timeframe for achievement. Effective outcome criteria in a nursing care plan must be SMART: specific, measurable, achievable, relevant, and time-bound. Without a deadline, the nurse cannot objectively evaluate whether the intervention was successful at a particular point in the client's recovery. While stating pain is less than or equal to 5 is measurable, the absence of a temporal component makes the goal clinically incomplete.

Choice B rationale

This is a correctly written outcome goal because it is specific and includes a clear timeframe. It identifies the subject, the measurable action using a standardized 0 to 10 pain scale, and a target window of 24 hours. Pain management is a priority postoperatively, and setting a specific threshold like 4 allows the nursing team to evaluate the effectiveness of analgesics and other comfort measures accurately within the critical early recovery period following the surgical procedure.

Choice C rationale

This goal is unrealistic and poorly defined for a postoperative client. Expecting "no pain" immediately following surgery is often unachievable due to tissue trauma and the inflammatory response. Furthermore, it lacks a timeframe for when this state should be reached. Goals must be realistic to provide a sense of progress for the patient and the healthcare team. Aiming for a manageable pain level on a numeric scale is a more evidence-based and practical nursing approach.

Choice D rationale

This goal is correctly written as it uses a measurable scale and defines a clear endpoint, which is the time of discharge. Providing a target pain level of 3 or less ensures that the patient is comfortable enough to manage activities of daily living and follow-up care at home. Using the 0 to 10 scale provides an objective way to track progress throughout the hospital stay, making it a functional part of the postoperative nursing care plan.

Choice E rationale

This statement is an intervention, not an outcome goal. An outcome goal describes a desired change in the client's status or behavior as a result of nursing care, whereas an intervention describes the actions the nurse will take. Medicating a client is something the nurse does to help reach a goal, such as reduced pain scores. Furthermore, a goal should be client-centered, focusing on the patient's response rather than the nurse's scheduled activities or tasks.