A nurse is admitting a new client.
Which of the following steps of the nursing process is the nurse performing when formulating goals for a positive outcome?
Assessment.
Planning.
Evaluation.
Implementation.
The Correct Answer is B
Choice A rationale:
Assessment Assessment is the first step of the nursing process, where the nurse collects data about the patient's condition. While this step is crucial for understanding the patient's needs, it does not involve formulating goals for a positive outcome. Therefore, it is not the correct choice in this context.
Choice B rationale:
Planning Planning is the step of the nursing process where the nurse formulates goals and develops a care plan to achieve those goals. This includes setting objectives for the patient's care and determining the best course of action. In this case, the nurse is formulating goals for a positive outcome, making choice B the correct answer.
Choice C rationale:
Evaluation Evaluation is the step where the nurse assesses the patient's response to the care provided and determines whether the goals have been met. While important, it does not involve the initial formulation of goals, so it is not the correct choice for this question.
Choice D rationale:
Implementation Implementation involves carrying out the plan of care, putting the planned interventions into action. It doesn't focus on goal formulation, so it is not the correct answer in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Assisting the client to a side-lying position is not necessary when administering nasal decongestant drops. The client can be in an upright position or slightly tilted back.
Choice B rationale:
Holding the dropper 2 cm (1 in) above the naris is not a standard guideline for administering nasal decongestant drops. The dropper should be inserted into the nostril without touching the inside of the nostril to avoid contamination.
Choice C rationale:
Instructing the client to stay in the same position for 2 min is not necessary. After the administration of the nasal decongestant drops, the client can resume their normal activities.
Choice D rationale:
Telling the client to blow her nose gently before the instillation is the correct action. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.
Correct Answer is B
Explanation
Choice A rationale:
Health education involves providing information and knowledge to clients, but the nurse's action of blood pressure screening goes beyond mere education. It involves the actual screening for a specific health condition, which aligns better with health promotion.
Choice B rationale:
Health promotion encompasses actions aimed at enhancing an individual's well-being and preventing illness. Blood pressure screening is a preventive measure to identify individuals at risk of hypertension, making it a crucial component of health promotion. The nurse is contributing to the client's overall health by identifying potential hypertension issues.
Choice C rationale:
Holistic health refers to a broader approach to healthcare that considers the physical, mental, and social aspects of an individual. While it's important, the nurse's specific action of blood pressure screening doesn't necessarily encompass all these aspects. It's more focused on identifying a specific health condition.
Choice D rationale:
Disease prevention involves activities to prevent the occurrence or progression of diseases. Blood pressure screening falls under this category as it aims to prevent complications related to hypertension, making this choice a relevant consideration. However, "Health promotion" is a more precise and comprehensive description of the nurse's role in this scenario.
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