In developing an individualized plan of care for a patient, it is important for the nurse to
a. Set goals that are a little beyond the capabilities of the patient.
b. Use his or her judgment and not be swayed by family desires.
c. Establish goals that are measurable and realistic.
d. Explain that without taking alignment risks, there can be no progress.
C
The nurse must develop an individualized plan of care for each nursing diagnosis and must set goals that are individualized, realistic, and measurable. The nurse should set realistic expectations for care and should include the patient and family when possible. The goals focus on preventing problems or risks to body alignment and mobility.
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The nurse is assessing a newborn while the new parents watch. The nurse uses an ophthalmoscope to examine the back of the eye (the retina) and notes a positive red reflex. The nurse would explain to the parents that the red reflex indicates:
1. The absence of congenital cataracts. 2. The presence of intraocular hemorrhage. 3. The optic nerve has been traumatized during delivery. 4. Presence of amblyopia.
Order the description of the progressive phases of Walker's model of the "cycle of battering?"
1. ________ This phase is the most violent and the shortest, usually lasting up to 24 hours. 2. ________ In this phase, the man's tolerance for frustration is declining. 3. ________ In this phase, the batterer becomes extremely loving, kind, and contrite.
A middle-aged woman was obese and being treated for hypertension; and her blood tests showed elevated triglycerides and low high-density lipoprotein (HDL)
Besides recommending physical activity, which of the following nutritional guidance should be provided by the nurse? a. Buy a good diet book, and follow its advice. b. Eat fish and seafood such as salmon, halibut, tuna, and scallops at least three times a week. c. Use olive oil when you cook, especially if you are frying food. d. You have to lose weight, so stop all desserts and eat nothing but salads for 2 weeks.
A family member tells the nurse that she is worried about her grandmother driving. Which of the following would be most appropriate for the nurse to suggest? (Select all that apply.)
a. Avoid rush hour traffic. b. Buy and drive a very large heavy car. c. Do not converse with any passengers. d. Drive more slowly. e. Drive only during daylight. f. Leave the radio turned off.