A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?
Assessment
Evaluation
implementation
Planning
The Correct Answer is D
A. Assessment involves collecting and analyzing data about the client's health status, including their medical history, physical examination findings, and any other relevant information. This step is crucial for understanding the client's current condition and needs, but it precedes goal setting.
B. Evaluation is the step where the nurse determines whether the goals and outcomes established in the planning phase have been achieved. It involves assessing the effectiveness of interventions and making adjustments as needed. Evaluation occurs after goals have been set and interventions have been implemented, so it is not the step where goals are initially formulated.
C. Implementation involves carrying out the interventions and actions planned to achieve the goals established for the client. This step follows the formulation of goals and involves executing the planned care. While critical to achieving positive outcomes, implementation does not include the initial formulation of goals.
D. Planning is the step of the nursing process where the nurse formulates goals and develops a plan of care based on the assessment data. This includes setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided and achieve positive client outcomes. Planning is where goals are established to address the client’s identified needs and guide subsequent interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Intuition involves using a nurse’s instincts or "gut feeling" based on experience and familiarity with situations. While intuition can be valuable in clinical settings, it is not primarily concerned with interpreting data. Instead, it is more about making decisions based on a sense of what feels right or wrong, rather than analyzing and interpreting specific data.
B. Questioning involves asking pertinent questions to gather information, clarify uncertainties, and explore different aspects of a situation. This step helps in identifying what needs to be understood or investigated further but does not specifically refer to the act of interpreting data.
C. Creativity involves thinking outside the box, generating new ideas, and finding innovative solutions to problems. While creativity can aid in problem-solving and developing new approaches, it is not specifically related to interpreting data. Creativity is more about conceptualizing and brainstorming rather than analyzing and understanding data.
D. Analysis is the step in critical thinking where interpreting data fits. It involves examining, comparing, and contrasting data to understand its significance and implications. This step requires evaluating the information collected, identifying patterns or trends, and making sense of the data to support decision- making. Interpreting data is a key component of this analytical process, making it the most relevant choice for understanding and evaluating information.
Correct Answer is ["A","B","D","E"]
Explanation
A. A case manager coordinates and manages the overall care of the client, particularly when there are multiple healthcare needs or transitions in care. Given that the client has just experienced a CVA, the case manager could be crucial in coordinating care, arranging for additional services, and ensuring continuity of care, especially since the client lives alone.
B. The client is experiencing wheezing in the upper lobes of the lungs and is receiving supplemental oxygen. A respiratory therapist would be instrumental in evaluating and managing the client's respiratory status, including optimizing oxygen therapy and addressing any issues related to asthma or lung function.
C. There is no mention of diabetes in the client's history or current symptoms. The focus of the client's care is on managing the effects of the CVA and respiratory issues. Therefore, a referral to a diabetes nurse educator is not indicated based on the provided information.
D. The client has flaccid extremities with decreased muscle tone and strength following the CVA. A physical therapist would be essential for assessing and providing therapy to improve mobility, strength, and function in the affected extremities. This referral is appropriate for addressing the physical impairments resulting from the CVA.
E. The client is having difficulty with self-feeding due to decreased muscle tone and strength, which impacts daily activities. An occupational therapist can help with adaptive techniques and strategies for self-care tasks, such as feeding, and provide interventions to improve the client’s ability to perform daily activities independently. This referral is appropriate for addressing functional challenges related to the CVA.
F. An enterostomal therapy nurse specializes in wound care, ostomy management, and incontinence care. There is no indication in the provided information that the client has any issues related to wounds, ostomies, or incontinence. Therefore, a referral to an enterostomal therapy nurse is not indicated based on the current information.
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