A nurse is writing a care plan for a newly admitted patient. Which of the following outcome statements is written correctly?
A. "The patient will eat 80% of all meals."
B. "The nursing assistant will set up the patient for a bath every day."
C. "The patient will have improved airway clearance by May 30."
D. "The patient will identify the need to increase dietary intake of fiber by July 4."
D
An expected outcome is a measurable change in a patient's status that is expected to occur in response to nursing care. An outcome is an objective criterion for measuring goal achievement. Outcomes contain step-by-step guidelines with specific time frames for problem resolution.
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A child is diagnosed with congenital adrenal hyperplasia. The child's parents ask the nurse what this means. Which response by the nurse is the most appropriate?
A. "Your child is not producing ACTH." B. "Your child is not producing androgens." C. "Your child is not producing cortisol." D. "Your child is not producing corticosteroid-releasing hormone."
Which grieving behaviors should a nurse anticipate when caring for a Navajo client who recently lost a child?
1. Celebrating the life of a deceased person with festivities and revelry 2. Not expressing grief openly and reluctance to touch the dead body 3. Holding a prayerful vigil for a week following the person's death 4. Expressing grief openly and publicly and erecting an altar in the home to honor the dead
A client is scheduled to have an ankle-brachial index test. What should the nurse explain about the purpose of the test?
1. Measures the pressure of varicose veins. 2. Will determine whether atherosclerosis is present. 3. Predicts the likelihood of developing hypertension. 4. Measures cardiac ejection fraction.
During a history, the patient reports having gout. Based on this information, what findings does the nurse anticipate during a focused assessment?
a. Warm, tender, and deformed wrists and peripheral interphalangeal (PIP) joints bilaterally b. Edema, warmth, and redness of one great toe and pea-like nodules in the ear lobes c. Enlarged and tender PIP or distal interphalangeal (DIP) joints on one or several fingers d. Tenderness with pronation and supination of the elbow and point tenderness on the lateral epicondyle