A nurse is caring for a client who experienced short-term memory ...

[HCHenry]

A nurse is caring for a client who experienced short-term memory loss as a result of a head injury. Which of the following statements made by the nurse regarding goal setting requires follow-up by the nurse manager?
 
  1. The client will certainly need frequent reorientation to the care plan goals.
  2. I will restate the goals I've created for him regularly so as to win his compli-ance.
  3. I'm not sure that his family will be able to support him with these goals but I will discuss it with them.
  4. He seems very willing to work towards achieving his goals but his condition will certainly create barriers.

Question 2

The expected outcome that best evaluates the presurgical goal of, Client will understand pur-pose of coughing and deep breathing within 4 hours of returning to room is:
 
  1. Client will demonstrate proper technique for coughing and deep breathing
  2. Client will cough and deep breathe every 1 hour while awake without staff prompting
  3. Client is capable of restating the purpose of coughing and deep breathing in own words
  4. Client's lungs will be free of abnormal breath sounds within 1 hour of being re-turned to room

[srodz]

Answer to Question 1

ANS: 2
If a client or significant other is not able to participate in goal development, you assume responsi-bility until the client is able to participate. It is vital that to the degree that the client is capable, the client be included in the decision-making process. Frequent reorientation to the care plan goals may be true and so does not require follow-up. The nurse seems pessimistic about the fami-ly's ability to play a role in the client's care plan but declares that an attempt will be made to in-clude them; so follow-up is not an immediate priority. The client seems very willing to work to-wards achieving his goals may be true and so does not require follow-up because there is no in-dication of the nurse's intention to minimize his participation.

Answer to Question 2

ANS: 2
An expected outcome is a criteria designed to evaluate the achievement of the stated goal. This option best represents evaluation of the client's understanding of the purpose of deep breathing and coughing because it shows appropriate compliance. Although demonstration evaluates the proper technique, it is not the best option to evaluate understanding of purpose. Although re-statement evaluates understanding, it is not the best option to evaluate understanding of purpose because it does not include client compliance. The client's lungs being free of abnormal breath sounds within 1 hour is more reflective of a goal than of an expected outcome.

[HCHenry]

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