Author Question: Which of the following would be an appropriate nursing goal? 1. The client will raise her right ... (Read 29 times)

karateprodigy · **on:** Jul 22, 2018

Which of the following would be an appropriate nursing goal?

1. The client will raise her right arm to shoulder height by Friday.
2. The client will begin to use her right arm.
3. The client will not complain of pain in the right arm.
4. The client should not injure the right arm.

Question 2

The client complains of pain, and tells the nurse that the last time he got pain medication, it was dark outside.

The nurse checks the medical record and sees that the day shift nurse documented administering an injection of narcotic analgesics twice during the day. The client's wife says she was with him all day and he never received an injection. The nurse's priority action is to: 1. Call the Board of Nursing to notify them of falsification of records.
2. Notify the nursing supervisor immediately of the situation.
3. Call the day shift nurse to ask if the medication was actually given.
4. Complete an incident report.

JCABRERA33 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1
Rationale 1: Part of the planning process includes setting goals for the client that are specific, timed, and measurable. The client will begin to use the right arm does not offer a time frame or specify how the arm will be used, which would make evaluation of progress impossible. Lack of complaints of pain in the arm is not indicative the client doesn't have pain, only that no spontaneous reports are made. Lack of injury is too nonspecific, and would not be the best choice of goals.

Answer to Question 2

2
Rationale 1: The nursing supervisor should be notified. The nursing supervisor will investigate the situation to determine what actually occurred. The nurse should not jump to conclusions based on a small amount of information, so the Board of Nursing should not be notified and an incident report should not be completed at this time. It is not the nurse's responsibility to call the day shift nurse.