A nurse is reviewing the steps of the nursing process with a group of nursing students. Which of the following statements by one of the students indicates an understanding of the evaluation phase?

"It involves determining the effectiveness of nursing interventions.”.

"It involves establishing priorities and measurable outcomes.”.

"It involves identifying gaps between actual and expected findings.”.

"It involves selecting appropriate evidence-based interventions.".

Answer and Explanation

The Correct Answer is A

Choice A reason:

It involves determining the effectiveness of nursing interventions. This is the correct definition of the evaluation phase of the nursing process, which is the final step where the nurse compares the actual outcomes with the expected outcomes and modifies the plan of care if needed.

Choice B reason:

It involves establishing priorities and measurable outcomes. This is not the correct definition of the evaluation phase, but rather the planning phase of the nursing process, which is the third step where the nurse identifies client goals and interventions based on the nursing diagnosis.

Choice C reason:

It involves identifying gaps between actual and expected findings. This is not the correct definition of the evaluation phase, but rather a component of it. Identifying gaps between actual and expected findings is one way to determine the effectiveness of nursing interventions, but it is not the only way. The evaluation phase also involves documenting and communicating the results of the evaluation.

Choice D reason:

It involves selecting appropriate evidence-based interventions. This is not the correct definition of the evaluation phase, but rather another component of the planning phase of the nursing process, which is the third step where the nurse identifies client goals and interventions based on the nursing diagnosis.

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Correct Answer is A

Explanation

Choice A reason:.

Establishing a baseline for planning care and evaluating outcomes is the main purpose of the assessment phase of the nursing process. The assessment phase involves collecting data about the client's health status and needs, which will help the nurse to identify any problems or potential problems that may need to be addressed. The assessment data will also serve as a reference point for comparing the client's progress and outcomes throughout the nursing process.

Choice B reason:.

Identifying the client's response to health concerns or illness is part of the diagnosis phase of the nursing process. The diagnosis phase involves analyzing the data collected during the assessment phase and identifying the client's problems and strengths. The nurse then formulates a nursing diagnosis, which is a statement of the client's actual or potential health problem that can be addressed by nursing interventions.

Choice C reason:.

Providing goal-directed, client-centered care is part of the planning and implementation phases of the nursing process. The planning phase involves setting goals and outcomes for the client and selecting appropriate interventions to achieve them. The goals and outcomes should be specific, measurable, attainable, realistic, and timely (SMART), and they should reflect the client's preferences and values. The implementation phase involves carrying out the interventions and documenting the actions and responses. The interventions should be evidence-based, safe, and effective, and they should involve the client as much as possible.

Choice D reason:.

Comparing the client's data with expected standards or reference ranges is part of the evaluation phase of the nursing process. The evaluation phase involves evaluating the effectiveness of the interventions and modifying the plan as needed. The nurse compares the client's actual outcomes with the expected outcomes and determines whether the goals have been met, partially met, or not met. The nurse also identifies any factors that may have influenced the outcomes, such as client compliance, environmental factors, or unexpected events.

A. PES format (problem, etiology, signs and symptoms). B. PE format (problem, etiology). C. PS format (problem, signs and symptoms). D. ES format (etiology, signs and symptoms).

Correct Answer is A

Explanation

Choice A reason:

The PES format (problem, etiology, signs and symptoms) is the most comprehensive and accurate way to write a nursing diagnostic statement. It identifies the nursing problem, the cause or contributing factors, and the evidence or manifestations of the problem. For example, a possible PES statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern related to chronic airway obstruction as evidenced by dyspnea, tachypnea, and use of accessory muscles.

Choice B reason:

The PE format (problem, etiology) is a two-part diagnostic statement that omits the signs and symptoms of the problem. It is less specific and does not provide enough information to guide the nursing interventions and outcomes. For example, a possible PE statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern related to chronic airway obstruction. This statement does not indicate how the problem is manifested or measured.

Choice C reason:

The PS format (problem, signs and symptoms) is a two-part diagnostic statement that omits the etiology or cause of the problem. It is less precise and does not identify the factors that contribute to or influence the problem. For example, a possible PS statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern as evidenced by dyspnea, tachypnea, and use of accessory muscles. This statement does not indicate why the problem exists or what can be done to address it.

Choice D reason:

The ES format (etiology, signs and symptoms) is a two-part diagnostic statement that omits the problem or nursing diagnosis. It is incomplete and does not state what the actual or potential health issue is. For example, a possible ES statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Chronic airway obstruction as evidenced by dyspnea, tachypnea, and use of accessory muscles. This statement does not indicate what the nursing problem is or what the desired outcome is.

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A nurse is reviewing the steps of the nursing process with a group of nursing students. Which of the following statements by one of the students indicates an understanding of the evaluation phase?

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