Author Question: An expected client outcome is, The client will remain free of infection by discharge. When ... (Read 138 times)

student77 · **on:** Jul 23, 2018

An expected client outcome is, The client will remain free of infection by discharge.

When evaluating the client's progress, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000, and the client's abdominal wound has a half-inch gap at the lower end with yellow-green discharge. Which statement would be an appropriate evaluation statement?

A) Goal partially met; client identified fever and presence of wound discharge.
B) Client understands the signs and symptoms of infection.
C) Goal partially met; client able to perform activities of daily living.
D) Goal not met; white blood cell count elevated, presence of yellow-green discharge from wound.

Question 2

The client's expected outcome is The client will maintain skin integrity by discharge. Which of the following measures is best in evaluating the outcome?

A) The client's ability to reposition self in bed.
B) Pressure-relieving mattress on the bed.
C) Percent intake of a diet high in protein.
D) Condition of the skin over bony prominences.

31809pancho · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: D

During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse has three options: met, partially met, or not met. An elevated white blood cell count and the presence of yellow-green wound discharge are clinical manifestations consistent with an infectious process, so the outcome has not been met.

Answer to Question 2

Ans: D

During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse examines client data or behaviors that validate whether the outcome is met. The condition of the skin, especially over bony prominences, provides the best measure of whether skin integrity has been maintained.