A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." One of the following statements demonstrates that the nurse appropriately evaluated this goal.

Outcome not met. The client is able to state one positive aspect by the end of the week.

Outcome met. The client is able to state two positive aspects of therapy by week's end.

Outcome incomplete. The client is not able to positively state anything about rehab.

Outcome met. The client is able to state one positive aspect by the end of the week.

Answer and Explanation

The Correct Answer is B

This statement demonstrates that the nurse appropriately evaluated the goal because it shows that the client was able to meet the goal of stating two positive aspects of rehab therapy by the end of the week. The other statements indicate that the outcome was either not met, incomplete, or only partially met.

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Correct Answer is A

Explanation

A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.

A. Stage 3 B. Stage 4 C. Stage 2 D. Stage 1

Correct Answer is C

Explanation

A client who has accepted the fact that they need bypass surgery for a blocked artery and has been admitted to the hospital is experiencing Stage 2 of illness. Stage 2 is known as the prodromal period, during which the symptoms of illness begin to appear ². The other options (Stage 1, Stage 3, and Stage 4) are not correct.

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A client has the goal statement "Client will be able to state two positive aspects of rehab therapy by the end of the week." One of the following statements demonstrates that the nurse appropriately evaluated this goal.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

Correct Answer is A

Explanation

A client has accepted the fact that they need bypass surgery for a blocked artery and has been admitted to the hospital. Which one of the following stages of illness is this client experiencing?

Correct Answer is C

Explanation

A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem?

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed and says "leave me alone." Which subjective data should the nurse document?

The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

The nurse manager has determined that a new staﬀ nurse is demonstrating characteristics of a critical thinker. Which of the following did the manager observe the nurse perform? Select all that apply.

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+ and equal in radial, popliteal, and dorsalis pedis. What does the number "+3" represent?

The nurse is using the PED model to write a nursing diagnosis. Which nursing diagnoses demonstrate that the nurse used this model appropriately? Select all that apply.

A nurse is caring for a client who is scheduled for an elective surgical procedure. In order to ensure informed consent, the nurse should take which of the following actions?