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 ["A","C","D","E"]
Explanation
Choice A reason: Washing your hands thoroughly is an important measure to reduce the risk of infection. Hand washing is one of the most effective ways to prevent the transmission of germs that can cause diseases. Hand washing can remove dirt, bacteria, viruses, and other contaminants from the skin and prevent them from entering the body or spreading to others. The nurse should teach the client with AIDS to wash their hands frequently and properly, especially before and after eating, using the bathroom, touching their face, or handling any objects that may be contaminated.
Choice B reason: Avoiding cleaning your toothbrush with bleach is not a measure to reduce the risk of infection. Cleaning your toothbrush with bleach is not a recommended practice, as bleach is a harsh chemical that can damage the toothbrush and irritate the mouth. However, cleaning your toothbrush with bleach does not increase the risk of infection, as bleach can kill most germs that may be present on the toothbrush. The nurse should teach the client with AIDS to rinse their toothbrush with water after each use and replace it every 3 to 4 months or sooner if the bristles are worn or frayed.
Choice C reason: Avoiding raw fruits and vegetables is a measure to reduce the risk of infection. Raw fruits and vegetables may be contaminated with bacteria, parasites, or pesticides that can cause foodborne illnesses. The client with AIDS has a weakened immune system that cannot fight off these infections effectively and may develop serious complications, such as diarrhea, dehydration, or malnutrition. The nurse should teach the client with AIDS to wash, peel, or cook their fruits and vegetables before eating them and to avoid any that are bruised, moldy, or spoiled.
Choice D reason: Avoiding crowds is a measure to reduce the risk of infection. Crowds are places where many people gather and interact, such as public transportation, shopping malls, schools, or workplaces. Crowds increase the exposure to germs that can cause respiratory, gastrointestinal, or skin infections. The client with AIDS has a lowered resistance to these infections and may contract them more easily and severely. The nurse should teach the client with AIDS to avoid crowds as much as possible and to wear a mask, practice social distancing, and use hand sanitizer if they have to be in a crowded place.
Choice E reason: Not sharing toothpaste with family members is a measure to reduce the risk of infection. Sharing toothpaste with family members can transfer saliva, blood, or other body fluids that may contain germs that can cause oral, dental, or systemic infections. The client with AIDS is more susceptible to these infections and may also transmit the HIV virus to their family members through their body fluids. The nurse should teach the client with AIDS to use their own toothpaste and toothbrush and to store them separately from their family members' ones.
Correct Answer is A
Explanation
Choice A reason: Once the tissue has necrosed from high pressure, it does not regenerate is the best explanation, because it describes the mechanism and outcome of glaucoma. Glaucoma is a condition that causes increased intraocular pressure, which damages the optic nerve and the retina, the tissues that are responsible for transmitting and processing visual information. Once these tissues are necrosed, or dead, they do not regenerate, or grow back, resulting in irreversible vision loss.
Choice B reason: Glaucoma always leads to permanent blindness is not a good explanation, because it is inaccurate and pessimistic. Glaucoma does not always lead to permanent blindness, but rather to progressive vision loss that can be prevented or slowed down with early diagnosis and treatment. Glaucoma can cause peripheral vision loss, tunnel vision, or blind spots, but not necessarily complete blindness.
Choice C reason: Once retinal detachment occurs, it does not return to its normal state is not a good explanation, because it is irrelevant and misleading. Retinal detachment is a condition that occurs when the retina separates from the underlying layer of blood vessels, which can cause vision loss or blindness. However, retinal detachment is not caused by glaucoma, nor is it a common complication of glaucoma. Retinal detachment can sometimes be repaired with surgery, depending on the extent and duration of the detachment.
Choice D reason: Once bacterial infection has caused damage, the tissue does not regenerate is not a good explanation, because it is incorrect and confusing. Bacterial infection is not a cause or a consequence of glaucoma, but rather a separate condition that can affect the eye. Bacterial infection can cause inflammation, pain, discharge, or redness in the eye, but not necessarily vision loss or tissue necrosis. Bacterial infection can usually be treated with antibiotics, which can prevent or reverse the damage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.