The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client?
1. Assess the client's mental status.
2. Keep the client dependent on the staff for all care.
3. Make all choices for the client.
4. Remain free from injury.
Correct Answer: 4
Rationale 1: The nurse will need to assess the client's mental status to help accomplish this goal.
Rationale 2: Keeping the client dependent on the staff for care does not encourage independence.
Rationale 3: Making all choices for the client does not encourage independence.
Rationale 4: The major goal for a client who is at risk for injury is for the client to remain injury-free.
You might also like to view...
An adult patient has been assessed in the emergency department and diagnosed with necrotizing otitis externa. The primary care provider has prescribed ciprofloxacin
In preparation for administering this medication, what action should the nurse perform? A) Establish intravenous access. B) Remove as much cerumen as possible from the patient's ear canal. C) Flush the affected ear with warmed sterile water. D) Establish a sterile field around the perimeter of the ear.
The nurse is evaluating a client with diabetes 3 months after discharge from the hospital. The nurse determines that goals have been met if:
1. the fasting blood sugar is 130. 2. urine for ketones is positive. 3. the client is wearing cotton socks. 4. the client leaves her shoes and socks on.
The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain
When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness? A) The upper abdominal quadrants on the left and right side B) The costovertebral angle C) Above the symphysis pubis D) Around the umbilicus
In order for a client to be diagnosed with an anxiety disorder, the client must have had symptoms for longer than which time frame?
A) 1 week B) 2 weeks C) 3 weeks D) 1 month