When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

Modify the nursing interventions to achieve the client's goals.

Determine if the expected outcomes were realistic.

Obtain current client data to compare with expected outcomes.

Review related professional standards of care.

Answer and Explanation

The Correct Answer is C

Choice A reason: Modifying nursing interventions is a step that may be necessary after evaluating the effectiveness of care, but it is not the immediate next action after reviewing the expected outcomes.

Choice B reason: Determining if the expected outcomes were realistic is part of the evaluation process, but it requires current data to make an informed decision.

Choice C reason: Obtaining current client data is essential to compare with the expected outcomes and determine if the goals of care are being met.

Choice D reason: Reviewing related professional standards of care is important for ensuring quality care, but it is not the direct next step in evaluating the effectiveness of the client's nursing care.

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Correct Answer is C

Explanation

The correct answer is choice C. “This must be a very difficult time for you.”

Choice A rationale:

Asking the mother why she thinks it is her fault can make her feel defensive and does not provide the emotional support she needs at this moment. It may also imply that there could be a reason for her to feel guilty, which is not helpful.

Choice B rationale:

While it is important to provide hope and information about the prognosis, this response does not address the mother’s immediate emotional distress and feelings of guilt. It focuses on the future rather than acknowledging her current emotional state.

Choice C rationale:

This response is empathetic and acknowledges the mother’s feelings. It provides emotional support and validates her experience, which is crucial in helping her cope with the situation.

Choice D rationale:

Telling the mother she did nothing wrong is important, but it does not fully address her emotional distress. It is a factual statement that may not provide the comfort and understanding she needs at this moment.

A. Slip-on rubber shower shoes B. Tennis shoes with Velcro C. Leather-soled loafers D. Rubber-soled slippers

Correct Answer is B

Explanation

Choice A reason: Slip-on rubber shower shoes are not recommended as they do not provide the necessary support or stability for a client with weakness on one side.

Choice B reason: Tennis shoes with Velcro are ideal as they offer good support and are easy to fasten, which is beneficial for a client with one-sided weakness and potentially limited dexterity.

Choice C reason: Leather-soled loafers can be slippery and do not offer the snug fit and support needed for safe ambulation post-stroke.

Choice D reason: Rubber-soled slippers may provide some grip but typically do not offer the structured support that is necessary for a client with post-stroke weakness.

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When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mother of a child born with Tetralogy of Fallot asks the nurse, "Why did this happen to my baby? What did I do wrong?" Which response by the nurse is most helpful?

Correct Answer is C

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The nurse is teaching a spouse how to care for a client who recently had a stroke and has residual weakness on the right side. Which style of shoes should the nurse recommend the client wear when ambulating with the spouse's assistance?

Correct Answer is B

Explanation

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