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 D

Explanation

D. This ensures effective communication between the nurse and the client, allowing the client to express their concerns and enabling the nurse to provide appropriate care and support. Using a bilingual interpreter helps ensure accurate understanding and promotes culturally sensitive care.

A. Involving a family member can provide emotional support and assistance with communication. However, if the family member does not speak the client's language, this intervention may not fully address the client's immediate needs.

B. Asking for the support of a friend can provide emotional support and assistance with communication. However, if the friend does not speak the client's language, their presence is not useful

C. This intervention can help convey information and instructions to the client and may help alleviate fear by providing visual cues. However, it may not fully address the client's need for verbal communication or reassurance.

Correct Answer is ["1"]

Explanation

There are 5 mL in one teaspoon, and 1 tablespoon is equivalent to 3 teaspoons, there are 15 mL in one tablespoon.

So, if 15 mL contains 30 mg of dextromethorphan, then:

1 tablespoon (15 mL) contains 30 mg of dextromethorphan.

Therefore, the nurse should instruct the client to take: 1 tablespoon

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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

The nurse is assessing a client in the clinic who is frightened and does not understand English. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

Correct Answer is ["1"]

Explanation

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

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