How would a nurse document the condition in which a client has a normal state of awareness?

"Easily distracted, alternates between drowsiness and excitability."

"Disoriented, restless, agitated, hallucinating."

"Can't be aroused and does not respond to stimuli."

"Aware of self and environment."

Answer and Explanation

The Correct Answer is D

A normal state of awareness is characterized by being aware of oneself and one's surroundings. In this case, a nurse would document the client's condition as being "aware of self and environment" to indicate that the client has a normal state of awareness.

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Correct Answer is A

Explanation

This statement indicates a need for further teaching because it is not accurate. Positioning a client in good body alignment and changing the position regularly are essential aspects of nursing practice, but the position should be changed more frequently than every 3 hours. It is generally recommended to reposition clients at least every 2 hours to prevent pressure ulcers and other complications. The other options (Frequent change in position helps to prevent muscle discomfort, undue pressure resulting in pressure ulcers, damage to superficial nerves and blood vessels, and contractures; Any position, correct or incorrect, can be detrimental if maintained for a prolonged period; and For all clients, it is important to assess the skin and provide skin care before and after a position change) are accurate statements and do not indicate a need for further teaching.

A. Client will have freer movement in daily activities. B. Client will ambulate without a walker by 6 weeks. C. Client will not fall. D. Client will ambulate frequently in the house.

Correct Answer is B

Explanation

An appropriate outcome statement for a client with a discharge goal of improved mobility should be specific, measurable, achievable, relevant, and time-bound. In this case, the outcome statement "Client will ambulate without a walker by 6 weeks" meets these criteria. It specifies the desired outcome (ambulating without a walker), provides a measurable goal (6 weeks), is achievable and relevant to the client's goal of improved mobility, and includes a time frame for achieving the goal. The other statements are not specific or measurable enough to be considered appropriate outcome statements.

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How would a nurse document the condition in which a client has a normal state of awareness?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a nursing student's understanding of positioning clients. Which of the following statements indicates a need for further teaching?

Correct Answer is A

Explanation

A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately?

Correct Answer is B

Explanation

The nurse has been caring for a client for several days and has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the client in improving his nutritional intake?

A nurse is conducting an assessment on a client diagnosed with narcolepsy. The nurse should anticipate which of the following findings? Select all that apply.

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?

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?

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent?

The client who has sleep apnoea reports falling asleep while driving, almost being involved in an accident, and frequent episodes of sleepwalking. What nursing diagnosis should be a priority for this client?

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?