A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient?

Correct Answer: C

Rationale: The correct answer is C because it is a realistic goal for a patient with a pelvic fracture on bed rest. The patient needs to use a walker correctly to ambulate safely to the bathroom, which promotes mobility and independence while ensuring safety. This goal is specific, measurable, achievable, relevant, and time-bound. Choice A is incorrect because increasing activity level may not be safe or feasible for a patient with a pelvic fracture. Choice B is incorrect as turning every 2 hours may not be necessary or practical for this patient. Choice D is incorrect as using a sliding board may not be appropriate or necessary for someone with a pelvic fracture.

Correct Answer: D

Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation involves determining if the patient's condition has improved and if the expected outcomes have been met. The nurse assesses the patient's progress, compares it to the expected outcomes set during planning, and determines the effectiveness of the interventions implemented. This step ensures that the care provided is meeting the patient's needs and helps in making any necessary adjustments to the care plan. Incorrect choices: A: Assessment - This step involves gathering information about the patient's condition and needs at the beginning of the nursing process. B: Planning - Involves setting goals and developing a plan of care based on the assessment data. C: Implementation - Involves carrying out the interventions outlined in the care plan to meet the patient's goals.

Correct Answer: A

Rationale: The correct answer is A because continuous assessment allows for timely identification of changes in the client's condition. This is crucial for providing appropriate and timely interventions. Assessing the client only at specific times (choices B and C) may lead to missing important changes. Choice D is incorrect because assessments should not be limited to physician rounds; they should be ongoing to ensure comprehensive care.

Correct Answer: A

Rationale: The correct answer is A: Client’s wife. She is the primary source of information as she witnessed the event firsthand and provided relevant details. In this scenario, the wife's account of the event is crucial in understanding the sequence of events leading to the client's unconscious condition. Medical documents (B), test results (C), and assessment data (D) are all secondary sources of information that may provide additional data but do not have the same level of immediacy or firsthand knowledge as the client's wife. In an emergency situation, information from a reliable eyewitness is often the most valuable initial source for healthcare providers to make critical decisions.

Correct Answer: B

Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying potential complications that may arise due to the client's health issue. This is important for developing effective interventions to prevent or manage these complications. Choice A focuses on the client's problem itself, not on potential complications. Choice C is related to nursing diagnosis, not collaborative problems. Choice D refers to medical diagnosis, which is different from collaborative problems involving nursing and other healthcare disciplines. Therefore, B is the correct focus for a diagnostic statement in a collaborative problem scenario.