Author Question: The nurse is formulating the patient's care plan. In determining when to evaluate the patient's ... (Read 53 times)

kaid0807 · **on:** Jul 23, 2018

The nurse is formulating the patient's care plan. In determining when to evaluate the patient's progress, the nurse is aware that evaluations:

a. must be done at the end of every shift.
b. should be done at least every 24 hours.
c. depend on intervention and patient condition.
d. are always done at time of discharge.

Question 2

Which goal is written correctly for the nursing diagnosis of activity intolerance related to imbalance between oxygen supply and demand?

a. Patient will walk 1 mile without shortness of breath.
b. Patient will ambulate 100 feet with no shortness of breath on third day after treatment.
c. Patient will climb stairs without shortness of breath by day 2 of hospital stay
d. Patient will tolerate activity.

Dnite · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: C
In most cases, goal statements need to include a time for evaluation. The time depends on the intervention and the patient's condition. Some goals may need to be evaluated daily or weekly, and others may be evaluated monthly. The health care setting affects the time of evaluation. If the goal is set during hospitalization, the goal may need to be evaluated within days, whereas a goal set for home care may be evaluated weekly or monthly. At the time of evaluation, the goal is assessed for goal attainment, and new goals are set or a new evaluation date for the same goal may be chosen if the goal is still applicable for the patient care plan.

Answer to Question 2

ANS: B
Useful and effective goals have certain characteristics. They are appropriate in terms of nursing and medical diagnoses and therapy. The goals are realistic in terms of the patient's capabilities, time, energy, and resources, and they are specific enough to be understood clearly by the patient and other nurses. They can be measured to facilitate evaluation. In option A, there is no time frame to gauge expectations so the diagnosis is not measurable. In option C, the number of stairs is not specified and so is not measurable. In option D, the type of activity is not mentioned so it is not specific and there is no measurable criterion.