The nurse is creating a plan of care for a client experiencing a situational crisis. Which is the most measurable and obtainable goal for the client to achieve?

The client will discover a new sense of self-sufficiency in coping

The client will express anger regarding the crisis event.

The client will resume the pre crisis level of functioning

The client will identify possible causes for the crisis

Answer and Explanation

The Correct Answer is C

When creating a plan of care for a client experiencing a situational crisis, it is important to set measurable and obtainable goals that can guide the client's progress and provide clear indicators of achievement.

Considering the options provided, the most measurable and obtainable goal for the client experiencing a situational crisis would be:

The client will resume the pre-crisis level of functioning.

This goal is measurable as it involves assessing the client's functioning before the crisis and monitoring their progress in returning to that level. It is also obtainable as it focuses on restoring the client's previous abilities and skills, rather than relying on subjective or introspective factors. By setting specific criteria to determine the pre-crisis level of functioning and regularly evaluating the client's progress, the nurse can measure the client's achievement of this goal and adjust the plan of care accordingly.

The client will resume the pre-crisis level of functioning: Resuming the pre-crisis level of functioning is a measurable and obtainable goal. It involves identifying the client's previous level of functioning and working towards returning to that state. By assessing the client's functional abilities before the crisis and monitoring progress over time, it is possible to measure and track the extent to which they have regained their previous level of functioning.

The client will discover a new sense of self-sufficiency in coping: While this goal is important for the client's long-term growth and development, it is not easily measurable or obtainable in a specific timeframe. "Discovering a new sense of self-sufficiency" is a subjective and introspective process that may require extensive self-reflection and personal growth, making it difficult to measure and set a concrete timeline for achievement.

The client will express anger regarding the crisis event: Expressing anger can be a normal and healthy part of the healing process during a crisis. However, it is not necessarily the most

measurable or obtainable goal. The expression of anger can vary greatly among individuals, and it may not be an appropriate or necessary response for everyone. Additionally, the focus of the plan of care should extend beyond anger expression and encompass a broader range of emotions and coping strategies.

The client will identify possible causes for the crisis: While understanding the possible causes of the crisis can be an important part of the recovery process, it may not be the most measurable or obtainable goal on its own. Identifying the causes of a crisis can involve complex factors that may require professional assessment and a deeper exploration of the client's history and circumstances. It is more appropriate as an ongoing process within therapy rather than a specific goal with a clear endpoint.

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Correct Answer is ["A","D","E"]

Explanation

The statements by the client that would require the nurse to notify the health care provider to cancel the MRI procedure are:

● “I had a pacemaker inserted a few years ago because my heart was not beating fast enough.”

● "I fell down my basement steps last year and broke my hip and had to have a hip replacement.”

● “When I was diagnosed with mitral valve prolapse, they had to replace the valve with a prosthetic valve."

These statements indicate that the client has metallic implants or devices in their body, which can be affected by the strong magnetic field of an MRI machine. This can pose a risk to the client’s safety and may interfere with the accuracy of the MRI results.

The other statements do not necessarily require the cancellation of the MRI procedure, but the nurse may need to take additional precautions or provide additional support to ensure the client’s comfort and safety during the procedure.

Here is a detailed explanation of why the other choices do not necessarily require the cancellation of the MRI procedure:

● “I have such terrible anxiety, I don’t know if I can remain still throughout the procedure.”: While anxiety can make it difficult for a client to remain still during an MRI procedure, it does not necessarily require the cancellation of the procedure. The nurse may provide additional support or medication to help the client manage their anxiety and remain still during the procedure.

● “I have diabetes mellitus type and have been taking insulin for many years.”: Having diabetes and taking insulin does not necessarily require the cancellation of an MRI procedure. The nurse may need to take additional precautions to ensure that the client’s blood sugar levels are stable during the procedure, but it does not pose a direct risk to the client’s safety or interfere with the accuracy of the MRI results.

A. "Set firm limits and boundaries for the client." B. “Tell the client that you are going to report to the director of the unit.” C. "Walk away and have someone else take care of the client." D. "It happens frequently so just ignore it they will stop."

Correct Answer is A

Explanation

When encountering a client who is sexually aggressive, it is important for the nurse to establish firm limits and boundaries to ensure the safety and well-being of both the client and the healthcare team. This response promotes the maintenance of a therapeutic environment and helps prevent potential harm to the client, staff, and other patients.

the other choices are incorrect:

1. "Tell the client that you are going to report to the director of the unit." While it is important to report any concerning behaviors or incidents to the appropriate personnel, simply informing the client about reporting to the director may not be the most effective initial response. Prioritizing immediate actions to ensure safety and setting boundaries is crucial before involving higher-level staff.

2. "Walk away and have someone else take care of the client." Leaving the situation and passing the responsibility to someone else without addressing the issue directly is not an appropriate response. It is the nurse's responsibility to provide care and manage challenging situations within their scope of practice and training. Collaboration and support from the healthcare team may be sought, but abandoning the client is not an acceptable approach.

3. "It happens frequently, so just ignore it; they will stop." Ignoring sexually aggressive behavior is not an appropriate response. Such behavior should be taken seriously and addressed promptly to ensure the safety and well-being of everyone involved. Ignoring the behavior may enable its continuation and potentially lead to further harm or escalation of the situation.

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The nurse is creating a plan of care for a client experiencing a situational crisis. Which is the most measurable and obtainable goal for the client to achieve?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for a magnetic resonance imaging (MRI). Which statement(s) by the client would require the nurse to notify the health care provider to cancel the procedure? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

A novice nurse is beginning work on a behavioral health unit and states to the preceptor, "What if I encounter a client that is sexually aggressive? Which is the appropriate response by the preceptor?

Correct Answer is A

Explanation

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