A nurse is caring for an elderly patient with a sleeping disorder. When formulating a care plan for this patient it was determined that the goal will be that "the patient establishes a healthy sleep pattern
" Which of the following is the best example of a measurable outcome to meet this goal? a. The patient will fall asleep more easily.
b. The patient will sleep longer throughout the night.
c. The patient will have less than two awakenings throughout the night.
d. The patient will wake up more refreshed in the morning.
C
Outcomes serve as measurable guidelines to determine goal achievement. "Less than two awakenings" is a measurable goal. The other responses are subjective (more easily, sleep longer, more refreshed) and do not have a measurable outcome.
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An 88-year-old client is admitted with an extracellular fluid volume excess. On admission, he is frightened and exhibiting dyspnea. On assessment, the nurse would expect to identify:
1. a weak, thready pulse. 2. poor or sluggish skin turgor. 3. neck vein distention. 4. postural hypotension.
The nurse notes that a client who has been using psoralens–ultraviolet A (PUVA) therapy for psoriasis for 1 month has darkening of the skin. Which is the nurse's best action?
a. Document this assessment finding. b. Instruct the client to reduce the dose. c. Instruct the client to drink more water. d. Instruct the client to apply cortisone cream.
A child is admitted to the hospital with spastic cerebral palsy. The nurse will assess for which manifestations associated with this disorder?
a. Tremulous movements at rest and with activity b. Sudden jerking movement caused by stimuli c. Writhing, uncontrolled, involuntary move-ments d. Clumsy, uncoordinated movements
The psychiatric-mental health nurse attends a presentation on various theories of mental disorders. Which comment by the psychiatric nurse indicates an understanding of intrapersonal theories of personality development?
A) "Personality is manifested only in a person's interactions with another person or group.". B) "Personality is more strongly shaped by events occurring in the earliest years of life than by those occurring later.". C) "Every human's personality is genetically driven and individually developed.". D) "People become who they are through a learning process using reinforcements and punishments.".