The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula.
Which action should the nurse include in the client's care?

Choice A rationale

Performance criteria describe the measurable qualities or the level of performance expected from the client, such as the distance walked or the accuracy of a task. In the stated goal, the phrase with 2-person assist already serves as a performance criterion or modifier by defining how the transfer must occur. Therefore, the performance criteria are technically present in the goal, and this is not the missing element.

Choice B rationale

Client behavior represents the specific action the client is expected to perform, which must be observable and measurable. In this clinical goal, the behavior is identified as the act of transferring from the bed to the chair. Since the action of transferring is clearly stated, the behavior component is already included in the nursing outcome statement and does not need to be added by the nurse.

Choice C rationale

Conditions or modifiers define the specific circumstances under which the behavior is to be performed, such as using equipment or receiving help. The phrase with 2-person assist acts as the condition for the transfer. Because these modifiers are already incorporated into the written goal, adding more conditions is not the primary requirement for completing this specific outcome according to standard nursing process guidelines.

Choice D rationale

A target time is a critical component of a SMART goal, indicating when the outcome is expected to be achieved. The current goal lacks a deadline, such as by discharge or within forty-eight hours. Without a specific timeframe, the nurse cannot effectively evaluate whether the client is progressing at an appropriate rate. Adding a target time ensures the goal is measurable and time-bound for evaluation.

Choice A rationale

This question is therapeutic because it uses an open-ended approach to encourage the client to explore potential stressors or environmental factors affecting their sleep. By asking for the client's perspective, the nurse fosters a collaborative relationship and gathers subjective data essential for a comprehensive assessment. This allows the client to reflect on habits or anxieties that might not be immediately obvious, providing a deeper understanding of the underlying causes of insomnia.

Choice B rationale

Asking about activities during wakefulness is a therapeutic technique that assesses the client's sleep hygiene and behavioral responses to insomnia. It helps identify if the client is engaging in stimulating activities, such as using electronic devices or consuming caffeine, which can further disrupt the circadian rhythm. Understanding these behaviors allows the nurse to provide targeted education on stimulus control therapy, which is a key component in treating chronic sleep disturbances and improving rest quality.

Choice C rationale

Asking how a client ended up with a problem can be perceived as accusatory or judgmental, which shuts down therapeutic communication. This phrasing implies that the client is responsible for their condition or that there is a linear, avoidable cause. Therapeutic communication should focus on the present state and future solutions rather than assigning blame. It is more effective to use non-judgmental language that invites the client to describe their experience chronologically.

Choice D rationale

The use of why questions is generally non-therapeutic in nursing because it often puts the client on the defensive. Such questions require the client to provide a justification for their physiological or psychological state, which they may not consciously understand. This can create a barrier to open sharing and may cause the client to feel scrutinized. Instead, the nurse should use what or how questions to elicit descriptive information without demanding an explanation.

Choice E rationale

Inquiring about previous attempts to manage the problem is therapeutic because it recognizes the client's autonomy and identifies what strategies have been successful or unsuccessful. This information prevents the nurse from suggesting interventions that the client has already found ineffective. It also provides insight into the client's coping mechanisms and health literacy. Assessing past trials is a standard part of a nursing history to ensure that the proposed care plan is personalized.