Author Question: A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An ... (Read 77 times)

imowrer · **on:** Jul 23, 2018

A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated.

A goal for this client is not to sustain any injuries for the next month. The client however, has fallen several times. In this situation, the nurse should do which of the following?
1. Review the data and make sure that the diagnosis is relevant.
2. Investigate whether the best nursing interventions were selected.
3. Modify the whole nursing plan.
4. Discard the nursing plan and start over from the assessment phase.

Question 2

A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours.

As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan?
1. The goal statement is written inaccurately.
2. The interventions are dependent of nursing.
3. The goal is unrealistic.
4. The interventions are not clear enough.

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

Answer to Question 1

Correct Answer: 2
Rationale 1: The data presented are relevant for the diagnosis selected in this case.
Rationale 2: Even if all sections of the care plan appear to be satisfactory, the manner in which the plan was implemented may have interfered with goal achievement. The nurse needs to check and see if the interventions were appropriate for the client. If the interventions selected did not help the client achieve the goal, then rearranging or implementing new ones may be necessary.
Rationale 3: The data presented are relevant for the diagnosis selected in this case, and it is not necessary to modify the whole plan.
Rationale 4: The data presented are relevant for the diagnosis selected in this case, and it is not necessary to discard the whole plan and start over. Modifications may be the key to a successful outcome for the client.

Answer to Question 2

Correct Answer: 3
Rationale 1: The goal statement is written accurately inclusive of all required components.
Rationale 2: Dependent interventions would be appropriate in this situation.
Rationale 3: When a care plan needs to be modified, discontinued, or changed in some manner, several decisions need to be made. If the nursing diagnosis is accurate, as it is in this case, the nurse should check to see if the goals are attainable and realisticthe flaw in this plan. A client with terminal cancer is not going to be pain-free, regardless of the amount of medication delivered. To think otherwise is inappropriate.
Rationale 4: The interventions are clearly written.