A patient with a fall risk has a goal to remain injury-free during the shift. Which finding best supports evaluation of this goal?
Correct answer: B. The patient remains free from falls and uses the call bell
- A. The patient says the ward feels comfortable
- B. The patient remains free from falls and uses the call bell
- C. The nurse explains the fall-prevention policy once
- D. The patient receives the prescribed evening medication
Explanation
Evaluation compares the patient's actual response with the planned measurable outcome. Remaining free from falls and using the call bell directly reflects safety, whereas comfort, teaching, and medication administration do not measure this goal.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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