When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Compare the client's manifestations with the defining criteria of related problems.

Review the priority nursing problems included in the plan of care.

List the nursing actions that need to be implemented most immediately.

Ensure that all treatments prescribed by the healthcare provider have been initiated.

Answer and Explanation

The Correct Answer is B

A. When identifying goals to be included in a client's plan of care, the nurse should compare the client's manifestations (signs and symptoms) with the defining criteria of related nursing problems or diagnoses. This involves assessing the client's current health status, identifying specific problems or areas of concern, and determining desired outcomes or goals for improvement.

B. Reviewing the priority nursing problems already included in the plan of care helps the nurse understand the client's current status and ongoing care needs. However, this may leave out other client needs not stated as priority

C. While listing immediate nursing actions is important for addressing urgent care needs, it does not directly address the process of identifying goals for the client's plan of care.

D. Ensuring that prescribed treatments have been initiated is an important aspect of client care, but it pertains more to implementation rather than goal identification.

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Correct Answer is B

Explanation

B. In three-point gait crutch walking, the client should progress to foot touchdown and weight bearing of the affected leg. This means that the client is able to advance the crutches forward, followed by the affected leg, and then the unaffected leg. The weight should be borne primarily by the hands and arms on the crutches while the affected leg supports some weight as tolerated.

A. Bearing body weight on the palms of hands during the crutch gait describes the correct distribution of weight on the crutches, which is important for proper technique, but it does not specifically address the coordination of crutch and leg movements in three-point gait.

C. Practices bicep and triceps isometric exercises is not directly related to proper crutch walking technique but may be beneficial for strengthening the upper extremities, which are involved in using crutches.

D. Inspects crutches to ensure rubber tips are intact is important for safety but does not specifically indicate understanding of proper crutch walking technique.

A. 1.015. B. 1.025. C. 1.005. D. 1.035.

Correct Answer is D

Explanation

D. Given the client's history of vomiting, diarrhea, and difficulty tolerating oral fluids, there's a likelihood of dehydration. Dehydration typically results in an increase in urine specific gravity due to the kidneys conserving water.

A. (1.015) and B (1.025) are within the reference range and would be more typical values for adequately hydrated individuals.

C. (1.005) is at the lower end of the reference range and would not be expected in a dehydrated individual.

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When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is demonstrating three-point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior indicates that the client understands proper crutch walking?

Correct Answer is B

Explanation

The nurse is assessing a client who reports a 3-day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]

Correct Answer is D

Explanation

The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

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