A nurse is using critical thinking skills to analyze data during the assessment phase of the nursing process. Which of the following actions should the nurse take?(Select all that apply).

Compare data with normal values and standards.

Organize data into clusters that have similar underlying causes.

Validate data by using multiple sources of information.

Document data using standardized terminology and abbreviations.

Prioritize data according to urgency and importance.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:

Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.

Choice B reason:

Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.

Choice C reason:

Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.

Choice D reason:

Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.

Choice E reason:

Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.

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Correct Answer is B

Explanation

Choice A reason:

Consulting with other members of the health care team is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While collaboration is important, the nurse should first involve the client in decision making to ensure that the plan of care is individualized, realistic and acceptable to the client.

Choice B reason:

Involve the client in decision making is the correct answer. This is the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. Involving the client in decision making promotes self-management, adherence and empowerment. The client is the best source of information about their preferences, goals and needs.

Choice C reason:

Reviewing current literature on diabetes management is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While evidence-based practice is essential, the nurse should first involve the client in decision making to ensure that the plan of care is based on the client's situation and values.

Choice D reason:

Identifying realistic and measurable outcomes is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While outcome identification is a key step in the nursing process, the nurse should first involve the client in decision making to ensure that the outcomes are relevant and achievable for the client.

A. The date and time of the evaluation. B. The methods used to measure outcomes. C. The revisions made to the plan of care. D. The rationale for choosing interventions. E. The comparison of outcomes with goals.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:

The date and time of the evaluation are essential to document because they provide a reference point for the progress of the patient and the effectiveness of the nursing interventions. They also help to establish a timeline of events and facilitate communication among the health care team.

Choice B reason:

The methods used to measure outcomes are important to document because they show how the nurse assessed the patient's condition and whether the expected outcomes were met, partially met, or not met. They also provide evidence of the quality and consistency of care provided by the nurse.

Choice C reason:

The revisions made to the plan of care are necessary to document because they reflect the changes in the patient's status and needs, as well as the nurse's clinical judgment and decision making. They also demonstrate the ongoing evaluation and adaptation of the nursing care plan to achieve optimal outcomes for the patient.

Choice D reason:

The rationale for choosing interventions is not required to document because it is part of the planning phase of the nursing process, not the evaluation phase. The rationale for choosing interventions should be based on evidence-based practice, standards of care, and clinical guidelines, which are already established and available for reference.

Choice E reason:

The comparison of outcomes with goals is essential to document because it shows whether the nursing care plan was effective in addressing the patient's problems and improving the patient's condition. It also helps to identify areas of improvement, gaps in care, and opportunities for learning and feedback.

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A nurse is using critical thinking skills to analyze data during the assessment phase of the nursing process. Which of the following actions should the nurse take?(Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has diabetes mellitus. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is documenting the results of an evaluation in a client's chart. Which of the following information should the nurse include? (Select all that apply.).

Correct Answer is ["A","B","C","E"]

Explanation

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