A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. Which goal statement is realistic for the nurse to assign to this patient?
Patient will increase activity level this shift.
Patient will turn side to back to side with assistance every 2 hours.
Patient will use the walker correctly to ambulate to the bathroom as needed.
Patient will use a sliding board correctly to transfer to the bedside commode as needed.
The Correct Answer is B
A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.
B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.
C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.
D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.
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Correct Answer is B
Explanation
A. Performing movements until the patient reports pain is inappropriate in passive range of motion, as the goal is to maintain joint function without causing discomfort.
B. Moving each joint to the point of resistance helps to maintain flexibility and prevent stiffness without causing harm, making this the appropriate technique.
C. Repeating movements five times by the patient is not applicable for passive range of motion, which is performed by the nurse on a patient who cannot do it themselves.
D. While smooth movements are essential, they should not be done quickly; the focus should be on the patient's comfort and safety, avoiding rapid or jerky motions.
Correct Answer is D
Explanation
A. Assessment has already been completed as the initial step, involving data collection.
B. Diagnosis is also completed, involving analysis and identification of the patient’s health problems.
C. Implementation occurs after planning, when nursing interventions are executed.
D. Planning is the appropriate next step, involving the creation of specific, measurable goals and interventions based on the identified nursing diagnoses.