Fundamentals of Nursing Q 37

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The following statements appear on a nursing care plan for a client after a mastectomy: Incision site approximated; absence of drainage or prolonged erythema at the incision site; and the client remains afebrile. These statements are examples of:

  

     A. Nursing interventions

     B. Short-term goals

     C. Long-term goals

     D. Expected outcomes

    

    

Correct Answer: D. Expected outcomes

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Goals or desired outcomes describe what the nurse hopes to achieve by implementing the nursing interventions and are derived from the client’s nursing diagnoses. One overall goal is determined for each nursing diagnosis. The terms goal, outcome, and expected outcome are oftentimes used interchangeably.

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Option A: Nursing interventions are activities or actions that a nurse performs to achieve client goals. Interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis.

Option B: Short-term goals can act as stepping stones to achieving longer-term targets. For example, a client may have the long-term goal of being able to groom herself, including cleaning her teeth, washing her face, combing her hair, and applying her make-up on her own. A short-term goal for this client might be to be able to clean her teeth.

Option C: Long-term goals are often used for clients who have chronic health problems or who live at home, in nursing homes, or extended-care facilities. Long-term goal indicates an objective to be completed over a longer period, usually over weeks or months.

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