A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, seems withdrawn, avoids eye contact and refuses to take part in conversation. In a loud, angry voice the client demands that the nurse leave the room. The nurse formulates a diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for the client? Select one answer

Choice A reason: Series of assessments that isolate a client’s health problem is not the best definition of the nursing process. The nursing process is not only a series of assessments, but also a series of actions that include planning, implementing, and evaluating the nursing care. The nursing process does not isolate a client’s health problem, but rather identifies and addresses the client’s holistic needs and responses to health and illness. Therefore, this choice is incorrect.

Choice B reason: Framework for the organization of individualized nursing care is the best definition of the nursing process. The nursing process is a framework that guides the nurse’s decision making and actions in providing individualized nursing care to each client. It involves five steps: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. It is based on scientific principles, ethical standards, and evidence-based practice. Therefore, this choice is correct.

Choice C reason: Preset formula for the design of nursing care is not the best definition of the nursing process. The nursing process is not a preset formula, but rather a dynamic and flexible method that adapts to the changing needs and situations of each client. It requires critical thinking, creativity, and clinical judgment from the nurse. It also involves collaboration and communication with the client and other members of the health care team. Therefore, this choice is incorrect.

Choice D reason: Method to assure that the physician’s orders are carried out correctly is not the best definition of the nursing process. The nursing process is not a method to assure that the physician’s orders are carried out correctly, but rather a method to provide independent and autonomous nursing care that complements or supplements the medical care. The nursing process reflects the nurse’s scope of practice, responsibility, and accountability for the client’s well-being. It also empowers the client to participate in their own care and achieve their health goals. Therefore, this choice is incorrect.

Choice A reason: Ineffective thermoregulation is a nursing diagnosis that indicates a problem with the body’s ability to maintain a normal temperature range. It can be caused by factors such as infection, inflammation, or environmental exposure. It can result in symptoms such as fever, chills, sweating, or shivering. The client’s temperature of 102oF (38.9oC) suggests that they have ineffective thermoregulation, but it is not the highest priority nursing diagnosis, as it is not immediately life-threatening. Therefore, this choice is incorrect.

Choice B reason: Decreased cardiac output is a nursing diagnosis that indicates a problem with the amount of blood pumped by the heart per minute. It can be caused by factors such as arrhythmias, heart failure, or shock. It can result in symptoms such as hypotension, tachycardia, dyspnea, or oliguria. The client’s heart rate of 144 beats/minute and irregular suggests that they have decreased cardiac output, which is the highest priority nursing diagnosis, as it can lead to organ failure or death if not treated promptly. Therefore, this choice is correct.

Choice C reason: Ineffective breathing patern is a nursing diagnosis that indicates a problem with the rate, rhythm, depth, or quality of respirations. It can be caused by factors such as airway obstruction, lung disease, or anxiety. It can result in symptoms such as dyspnea, cyanosis, or hypoxia. The client’s respiratory rate of 22 breaths/minute is within the normal range and does not indicate an ineffective breathing patern. Therefore, this choice is incorrect.

Choice D reason: Ineffective renal tissue perfusion is a nursing diagnosis that indicates a problem with the blood flow to the kidneys. It can be caused by factors such as renal artery stenosis, dehydration, or sepsis. It can result in symptoms such as oliguria, hematuria, or azotemia. The client’s vital signs do not indicate an ineffective renal tissue perfusion, and there is no evidence of renal impairment or dysfunction. Therefore, this choice is incorrect.