Author Question: A client has the goal statement Client will have clear lung sounds bilaterally within 3 days. One ... (Read 67 times)

nelaaney · **on:** Jul 23, 2018

A client has the goal statement Client will have clear lung sounds bilaterally within 3 days. One intervention to meet this goal is for the nurse to teach the client to cough and deep breathe and have the client do this several times every 2 hours.

At the end of the third day, the client's lungs are indeed clear. What should the nurse do to relate the intervention to the outcome?
1. Ask how many times per day the client practiced the coughing and deep breathing exercises.
2. Tell the client that the lungs are clear.
3. Document the assessment findings to show the effectiveness of the intervention.
4. Write this evaluation statement: Goal met, lung sounds clear by third day.

Question 2

A client has the goal statement Client will be able to state two positive aspects of rehab therapy by the end of the week. What statement demonstrates that the nurse appropriately evaluated this goal?

1. Goal not met, client able to state one positive aspect by the end of the week.
2. Goal met, client able to state one positive aspect by the end of the week.
3. Goal met, client able to state two positive aspects of therapy by week's end.
4. Goal incomplete, client not able to positively state anything about rehab.

rekilledagain · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1
Rationale 1: Part of the evaluating process is determining whether the nursing activities had any relation to the outcomes. Did the lungs clear because the client actually did the coughing and deep breathing? In order to know for sure, the nurse must collect more data and not assume that this particular nursing intervention had any relation to the outcome.
Rationale 2: Telling the client that his or her lungs are clear is not relating the intervention to the outcome because no mention of the intervention is made.
Rationale 3: Documenting does not show the effectiveness of the intervention.
Rationale 4: Writing an evaluation statement does not show the effectiveness of the intervention.

Answer to Question 2

Correct Answer: 3
Rationale 1: If the client can only state one aspect or it takes longer than a week, then the goal could be partially met.
Rationale 2: If the client can only state one aspect or it takes longer than a week, then the goal could be partially met.
Rationale 3: An evaluation statement consists of two parts: a conclusion and supporting data. The conclusion is a statement that the goal/desired outcome was met, partially met, or not met. The supporting data are the list of the client responses that support the conclusion. In this situation, the goal was met if the client was able to state two positive aspects of rehab by the end of the week, and the evaluation statement should reveal that.
Rationale 4: Using the word incomplete is not appropriate for the evaluation statement.