The client is able to ambulate without signs or symptoms of shortness of breath. Which statement by the nurse is the best example of an objective evaluation of the client's goal attainment?
1. "Client has no pain after ambulating."
2. "Client has no manifestations of nausea while up in hall."
3. "Client walked well and did not have any problem when up."
4. "Client has no evidence of respiratory distress when ambulating."
ANS: 4
"Client has no evidence of respiratory distress when ambulating" is the best example of an objec-tive evaluation of the client's goal attainment. It uses the same evaluative measures gathered during assessment and clearly describes objective data. "Client has no pain after ambulating" does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not pain. If the client's pain level were going to be used as an evaluative measure, it would be optimal to have the client report the pain using a pain scale to make it more measurable for comparison. "Client has no manifestations of nausea while up in hall" is not the best example of an objective evaluation of the client's goal attainment. It does not use the same evaluative measure gathered during assessment. The assessment measure concerned respiratory changes during ambulation, not nausea. Also, nausea is more subjective. "Client walked well and did not have any problem when up" is not the best example of an objec-tive evaluation. It includes the nurse's interpretation rather than documentation of objective data.
You might also like to view...
A family is informed that the brain damage to their daughter is irreversible. The father is later overheard making vacation plans and discussing what the family will do when his daughter leaves the hospital. The nurse recognizes the father is in which cri
a. High anxiety b. Denial c. Reconciliation d. Adaptation
Which of the following complementary alternative medicine therapies would be considered as part of the energy and body work category?
a. Rolfing c. shamanism b. imagery d. nutraceutical
A patient with epistaxis and a history of hemophilia A is admitted to the unit and is scheduled for replacement therapy. The nurse should prepare to administer
a. tranexamic acid (Cyklokapron). b. aminocaproic acid (Amicar). c. desmopressin (Stimate). d. factor VIII.
The nurse educator is reviewing the process of regulation of the female reproductive system. The nurse would arrange these steps in which order beginning with the initial step?
1. A surge of luteinizing hormone (LH) occurs 2. Ovarian follicles mature 3. Secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) 4. Secretion of gonadotropin-releasing hormone (GnRH) 5. The corpus luteum is formed