When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Compare the client's manifestations with the defining criteria of related problems.

Review the priority nursing problems included in the plan of care.

List the nursing actions that need to be implemented most immediately.

Ensure that all treatments prescribed by the healthcare provider have been initiated.

Answer and Explanation

The Correct Answer is B

A. When identifying goals to be included in a client's plan of care, the nurse should compare the client's manifestations (signs and symptoms) with the defining criteria of related nursing problems or diagnoses. This involves assessing the client's current health status, identifying specific problems or areas of concern, and determining desired outcomes or goals for improvement.

B. Reviewing the priority nursing problems already included in the plan of care helps the nurse understand the client's current status and ongoing care needs. However, this may leave out other client needs not stated as priority

C. While listing immediate nursing actions is important for addressing urgent care needs, it does not directly address the process of identifying goals for the client's plan of care.

D. Ensuring that prescribed treatments have been initiated is an important aspect of client care, but it pertains more to implementation rather than goal identification.

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Correct Answer is C

Explanation

C. The first action the nurse should take is to offer reassurance to the spouse that they are not alone. This statement acknowledges the spouse's emotional distress and provides comfort and support during a difficult time. It also validates the spouse's feelings of loneliness and acknowledges the importance of their presence and support for the client.

A and B focus on the client's illness or prognosis, which may not be the immediate concern for the spouse at this moment.

D, while valuable, may come after the initial reassurance to create a supportive environment for the spouse to share their feelings when they feel ready.

A. Stress reduction. B. Smoking cessation. C. Regular exercise. D. Low-fat diet.

Correct Answer is B

Explanation

B. Smoking is a significant risk factor for the development of cardiovascular disease, as it contributes to the narrowing and hardening of the arteries, increases blood pressure, reduces oxygen supply to tissues, and promotes the formation of blood clots.

A. Chronic stress can contribute to cardiovascular disease by raising blood pressure, increasing heart rate, and promoting inflammation.

C. Regular physical activity is crucial for cardiovascular health. It helps strengthen the heart muscle, lower blood pressure, improve cholesterol levels, control weight, and reduce stress.

D. A low-fat diet, particularly one that is high in fruits, vegetables, whole grains, and lean proteins, can help lower cholesterol levels, reduce blood pressure, and manage weight, all of which are important for heart health.

Although A, C, D play a role in preventing cardiovascular disease, smoking is the major risk factor for cardiovascular disease.

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When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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