Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?
Client will remain free from falls throughout their hospital stay.
Client will increase activity tolerance by discharge from the hospital.
Client will demonstrate effective breathing pattern when ambulating throughout hospital stay.
Client will increase mobility by the time of discharge from hospital.
The Correct Answer is A
Choice A reason: Client will remain free from falls throughout their hospital stay is the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is specific, measurable, attainable, realistic, and timely. This goal addresses the main risk factor for injury, which is falling, and the main outcome indicator, which is the absence of falls. This goal also reflects the client's condition, needs, and preferences, and is consistent with the standards of care and evidencebased practice.
Choice B reason: Client will increase activity tolerance by discharge from the hospital is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is vague, subjective, unachievable, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.
Choice C reason: Client will demonstrate effective breathing pattern when ambulating throughout hospital stay is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is irrelevant, unrelated, unnecessary, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.
Choice D reason: Client will increase mobility by the time of discharge from hospital is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is vague, subjective, unachievable, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "I will take all prescribed medications." is not a statement that demonstrates an understanding of the teaching, because it is incomplete and vague. Taking all prescribed medications is an important part of the treatment for HIV, but it does not explain why, how, or for how long the medications are needed. Taking all prescribed medications without understanding the purpose, benefits, or risks can lead to poor adherence, compliance, or outcomes.
Choice B reason: "I will only need to take HIV medications for 6 months, and then I will be cured." is not a statement that demonstrates an understanding of the teaching, because it is incorrect and unrealistic. Taking HIV medications for 6 months is not enough to treat the infection, and there is no cure for HIV. HIV is a chronic and incurable infection that requires lifelong treatment with antiretroviral drugs, which can suppress the viral load, improve the immune function, and prevent the progression to AIDS. Stopping the medications after 6 months can cause the virus to rebound, the immune system to deteriorate, and the disease to worsen.
Choice C reason: "I will have to take medications for the rest of my life." is a statement that demonstrates an understanding of the teaching, because it is accurate and realistic. Taking medications for the rest of one's life is the reality of living with HIV, as there is no cure for the infection. Taking medications for the rest of one's life can help control the infection, maintain the health, and prolong the survival of people with HIV.
Choice D reason: "I will have to be careful and avoid crowds." is not a statement that demonstrates an understanding of the teaching, because it is unnecessary and exaggerated. Being careful and avoiding crowds is not a requirement for people with HIV, as the infection is not transmitted by casual contact, such as touching, hugging, or sharing utensils. Being careful and avoiding crowds can also be detrimental to the social and emotional wellbeing of people with HIV, as it can cause isolation, stigma, or depression.
Correct Answer is A
Explanation
Choice A reason: Administering topical hydrocortisone is the appropriate nursing intervention, because it can help reduce the inflammation and itching of the skin lesions that are common in SLE. SLE is a chronic autoimmune disease that causes the immune system to attack various organs and tissues, such as the skin, joints, kidneys, heart, and blood vessels. Hydrocortisone is a type of corticosteroid that can suppress the immune response and relieve the symptoms of SLE.
Choice B reason: Applying cold therapy to the extremities is not the appropriate nursing intervention, because it can worsen the circulation and sensation of the fingers and toes that are affected by Raynaud's phenomenon, which is a complication of SLE. Raynaud's phenomenon is a condition that causes the blood vessels in the extremities to narrow and spasm in response to cold or stress, resulting in numbness, pain, and color changes. Cold therapy can trigger or aggravate Raynaud's phenomenon.
Choice C reason: Administering antibiotics is not the appropriate nursing intervention, because it is not indicated for SLE, unless there is a secondary infection. SLE is not caused by bacteria, but by the abnormal activity of the immune system. Antibiotics are drugs that can kill or inhibit the growth of bacteria, but they have no effect on the underlying cause of SLE. Antibiotics can also have side effects, such as allergic reactions, gastrointestinal disturbances, or resistance.
Choice D reason: Encouraging ultraviolet (UV) light exposure is not the appropriate nursing intervention, because it can trigger or worsen the skin lesions and the disease activity of SLE. UV light is a type of radiation that can damage the DNA and the cells of the skin, causing inflammation, redness, and blistering. UV light can also stimulate the production of antibodies and cytokines that can attack the organs and tissues of the body.
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