The nurse is planning care for a client at risk of falling. Which appropriately worded goals should the nurse include in the plan? Select All That Apply.

"The client will be taught how to call for help to ambulate."

"The client will be restrained when agitated."

"The client will be free from trauma."

"The client will be able to walk from a bed to a chair safely while hospitalized."

"The client will be kept on bed rest when dizzy."

Answer and Explanation

Correct Answer : C,D

Fall prevention strategies focus on mitigating environmental hazards and optimizing patient mobility to prevent musculoskeletal or head injuries. Effective nursing goals prioritize the maintenance of physical integrity and the achievement of specific, functional milestones during the hospital stay. By utilizing measurable outcomes, the nurse can objectively evaluate the success of safety interventions and adjust the plan of care to ensure continuous protection.

Rationale:

A. This statement describes a nursing intervention rather than a client-centered goal. An appropriately worded goal must focus on the behavior or status of the client, such as "The client will demonstrate the use of the call light." Goals should reflect what the patient will achieve, not the actions the nurse will perform during the shift.

B. Restraint use is a reactive safety measure and an intervention of last resort, not a positive client goal. Promoting a restraint-free environment is a standard of care, and goals should focus on maintaining safety through less restrictive means. A goal should describe a desired health state rather than the application of a restrictive mechanical device.

C. Remaining free from injury is the ultimate outcome for a patient at risk for falls. This goal is specific to the safety concern and provides a clear metric for evaluating the effectiveness of the fall prevention protocol. It addresses the prevention of fractures, lacerations, or other forms of physical harm during the nursing care period.

D. This goal is appropriately worded because it is measurable and contains a specific time frame (while hospitalized). It focuses on a functional task—walking from a bed to a chair—which allows the nurse to observe and document the client's ability to move without falling. Clear parameters allow for consistent evaluation by the multidisciplinary healthcare team.

E. Bed rest is an intervention that can lead to deconditioning and an increased risk of falls upon eventual mobilization. A goal should focus on rehabilitation or safety during necessary movement rather than the restriction of all activity. Prescribing bed rest is a provider-led intervention and does not constitute a SMART client-centered goal for mobility.

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Correct Answer is C

Explanation

Advance directives facilitate patient autonomy by documenting healthcare preferences before incapacitation. These legal instruments ensure that end-of-life decisions align with the individual's values, particularly during high-acuity surgeries where the risk of losing decision-making capacity is significant.

Rationale:

A. A DNR is a specific medical order signed by a physician, not a comprehensive advance directive. It only addresses cardiopulmonary resuscitation and is too narrow for a client needing broad representation during an upcoming emergency surgery.

B. A living will specifies treatment preferences but is often limited to terminal conditions or persistent vegetative states. In emergency surgery, it may not cover the real-time complexities and fluid clinical decisions required by the surgical team.

C. A durable power of attorney for health care (DPOA-HC) is ideal for surgical patients. It designates a healthcare proxy to make diverse medical decisions if the client is anesthetized or unconscious, ensuring continuous advocacy.

D. A general power of attorney typically grants authority over financial matters and legal transactions. It does not automatically provide the legal right to make medical choices, making it inappropriate for clinical end-of-life or surgical planning.

A. Select a bracelet like jewelry worn by peers. B. Ask friends to wear similar bracelets. C. Hide the bracelet under long-sleeved clothes. D. Wear the bracelet while engaging in contact sports.

Correct Answer is A

Explanation

Seizure disorders are chronic neurological conditions characterized by abnormal, excessive neuronal discharges in the cerebral cortex resulting in transient alteration of consciousness, motor activity, or behavior. Adolescents with epilepsy often experience psychosocial stressors including identity formation, peer conformity pressure, and reduced adherence to safety interventions such as medical identification systems. Failure to use medical alert identification increases risk of delayed emergency recognition, inappropriate treatment during ictal events, and preventable morbidity in out-of-hospital seizures. Effective adherence strategies rely on developmental appropriateness, autonomy support, and behavioral reinforcement aligned with adolescent psychosocial development.

Rationale:

A. This is correct because adolescent adherence improves when interventions support peer conformity and identity integration. Designing a medical alert bracelet that resembles fashionable jewelry reduces stigma and enhances self-acceptance, increasing likelihood of consistent wear during daily activities and emergency situations.

B. This is incorrect because it does not address medical necessity or individual risk disclosure. It may normalize appearance but does not ensure emergency identification, and peers do not require medical alert systems, limiting effectiveness in seizure-related emergencies.

C. This is incorrect because concealment reduces visibility and defeats the purpose of medical identification. Emergency responders rely on immediate visual cues, and covering the bracelet compromises rapid recognition during postictal or unconscious states.

D. This is incorrect because contact sports increase risk of trauma and potential injury from external force on the wrist. While wearing identification is appropriate, suggesting use specifically during high-impact activity does not address adherence barriers or adolescent psychosocial resistance.

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The nurse is planning care for a client at risk of falling. Which appropriately worded goals should the nurse include in the plan? Select All That Apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A nurse is caring for an adolescent client with a seizure disorder who refuses to wear a medical alert bracelet. Which strategy could the nurse suggest to help convince the client to wear a medical alert bracelet?

Correct Answer is A

Explanation

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