A nurse is developing an individualized plan of care for a ...

[Lisaclaire]

A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?
 
  a. Establish goals that are measurable and realistic.
  b. Set goals that are a little beyond the capabilities of the patient.
  c. Use the nurse's own judgment and not be swayed by family desires.
  d. Explain that without taking alignment risks, there can be no progress.

Question 2

Which patient will cause the nurse to select a nursing diagnosis of Impaired physical mobility for a care plan?
 
  a. A patient who is completely immobile
  b. A patient who is not completely immobile
  c. A patient at risk for single-system involvement
  d. A patient who is at risk for multisystem problems

[jaaaaaaa]

Answer to Question 1

ANS: A
The nurse must develop an individualized plan of care for each nursing diagnosis and must set goals that are individualized, realistic, and measurable. The nurse should set realistic expectations for care and should include the patient and family when possible. The goals focus on preventing problems or risks to body alignment and mobility.

Answer to Question 2

ANS: B
The diagnosis of Impaired physical mobility applies to the patient who has some limitation but is not completely immobile. The diagnosis of Risk for disuse syndrome applies to the patient who is immobile and at risk for multisystem problems because of inactivity. Beyond these diagnoses, the list of potential diagnoses is extensive because immobility affects multiple body systems.

[Lisaclaire]

Both answers were spot on, thank you once again

[jaaaaaaa]

Great! Please up vote