Which of these is an example of a goal rather than an outcome?

The client will ambulate 50 feet with a walker by day 3.

The client will maintain fluid balance as evidenced by stable weight and urine output.

The client will have improved gas exchange as indicated by oxygen saturation above 92%.

The client will have normal bowel function.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The client will ambulate 50 feet with a walker by day 3. This is an example of a goal rather than an outcome because it is a specific action that the client intends to achieve within a certain time frame. It is also a process goal because it is a step or sub-goal towards a more significant and overarching goal, such as improving mobility or preventing complications. Process goals are more controllable and measurable than outcome goals.

Choice B reason:

The client will maintain fluid balance as evidenced by stable weight and urine output. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

Choice C reason:

The client will have improved gas exchange as indicated by oxygen saturation above 92%. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

Choice D reason:

The client will have normal bowel function. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

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Correct Answer is B

Explanation

Choice A reason:

The client states that he has trouble sleeping at night. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice B reason:

The client has a blood pressure of 150/90 mm Hg. This is objective data because it is information that the nurse observes when conducting a physical assessment. Objective data is measurable and observable.

Choice C reason:

The client reports feeling anxious about his diagnosis. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice D reason:

The client prefers not to discuss his personal issues. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

A. The nurse checks the client's identification bracelet and verifies allergies. B. The nurse measures the client's blood pressure in both arms and compares with previous readings. C. The nurse asks the client if they have taken any over-the-counter medications or herbal supplements. D. The nurse reviews the most current evidence and guidelines for hypertension management. E. The nurse explains the purpose, procedure, and potential side effects of the intervention to the client.

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

Explanation

Choice A reason:

The nurse checks the client's identification bracelet and verifies allergies. This is an essential component of this skill because it ensures that the nurse is performing the intervention for the right client and avoids any potential adverse reactions or interactions due to allergies.

Choice B reason:

The nurse measures the client's blood pressure in both arms and compares with previous readings. This is not an essential component of this skill because it is not directly related to the intervention for hypertension. It is a part of the assessment process that should be done before planning the intervention.

Choice C reason:

The nurse asks the client if they have taken any over-the-counter medications or herbal supplements. This is an essential component of this skill because it helps the nurse to identify any possible factors that may affect the client's blood pressure or the effectiveness of the intervention. Some medications or supplements may interact with the prescribed drugs or alter the blood pressure level.

Choice D reason:

The nurse reviews the most current evidence and guidelines for hypertension management. This is not an essential component of this skill because it is not specific to the client's situation or needs. It is a part of the planning process that should be done before implementing the intervention.

Choice E reason:

The nurse explains the purpose, procedure, and potential side effects of the intervention to the client. This is an essential component of this skill because it respects the client's autonomy and informed consent. It also helps the client to understand what to expect and how to cope with any possible complications or discomforts.

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Which of these is an example of a goal rather than an outcome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting the data collected from a comprehensive physical exam of a client. Which of the following data should the nurse identify as objective data?

Correct Answer is B

Explanation

A nurse is reassessing a client before performing an intervention for a client who has hypertension. Which of the following are essential components of this skill? (Select all that apply.).

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

Explanation

A nurse is using critical thinking skills to analyze data during the assessment phase of the nursing process. Which of the following actions should the nurse take?(Select all that apply).

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