A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

Patient will increase activity level this shift.

Patient will turn side to back to side with assistance every 2 hours.

Patient will use the walker correctly to ambulate to the bathroom as needed.

Patient will use a sliding board correctly to transfer to the bedside commode as needed.

Answer and Explanation

The Correct Answer is B

A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.

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Correct Answer is A

Explanation

A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.
B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.
C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.
D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.

A. The patient would have died if nothing was done. B. The CPR procedure was done incorrectly. C. The patient was resuscitated according to the policy. D. The older patient with brittle bones might sustain fractures when chest compressions are done.

Correct Answer is B

Explanation

A. While the patient may have been in a life-threatening situation, this point is not necessarily a direct indictment of the nurse’s actions but rather a justification for performing CPR.
B. The prosecution will likely focus on whether the CPR was performed according to accepted standards of care. If it can be shown that the technique was inappropriate or negligent, this would support the claim of malpractice.
C. Performing CPR according to policy may serve as a defense for the nurse, emphasizing adherence to established protocols.
D. While it is true that older adults with brittle bones may be at risk for fractures, this is a known risk of CPR, and the prosecution will aim to demonstrate specific negligence or failure in technique rather than just acknowledging inherent risks.

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A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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