A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?
Planning
Evaluation
Data collection
Implementation
The Correct Answer is A
Choice A reason: This statement is correct because planning is the step of the nursing process that involves formulating goals and outcomes for a positive outcome. The nurse and the RN should collaborate with the client and other members of the healthcare team to identify the client's needs, priorities, and preferences, and develop a plan of care that is realistic, measurable, and client centered.
Choice B reason: This statement is incorrect because evaluation is the step of the nursing process that involves measuring the effectiveness of the plan of care and the achievement of the goals and outcomes. The nurse and the RN should compare the actual results with the expected results, and determine if the plan of care needs to be modified, continued, or terminated.
Choice C reason: This statement is incorrect because data collection is the step of the nursing process that involves gathering information about the client's health status, history, and environment. The nurse and the RN should use various sources and methods of data collection, such as interviewing, observing, examining, and reviewing records, and organize and document the data in a systematic and accurate way.
Choice D reason: This statement is incorrect because implementation is the step of the nursing process that involves carrying out the plan of care and providing the interventions. The nurse and the RN should perform the actions that are necessary to achieve the goals and outcomes, such as administering medications, providing education, or coordinating referrals, and document the interventions and the client's response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is false and should not be included in the teaching. Increase in saliva production does not increase the risk for dehydration, but rather helps to moisten the mouth and facilitate swallowing and digestion. Saliva production may decrease with aging due to factors such as medication side effects, dry mouth, or reduced fluid intake.
Choice B reason: This statement is false and should not be included in the teaching. Decrease in systolic blood pressure does not increase the risk for dehydration, but rather indicates a lower force of blood against the artery walls. Systolic blood pressure may decrease with aging due to factors such as reduced cardiac output, decreased vascular resistance, or orthostatic hypotension.
Choice C reason: This statement is true and should be included in the teaching. Decrease in kidney function increases the risk for dehydration, as it reduces the ability of the kidneys to concentrate urine and conserve water. Kidney function may decrease with aging due to factors such as reduced blood flow, decreased glomerular filtration rate, or loss of nephrons.
Choice D reason: This statement is false and should not be included in the teaching. Increase in percentage of body water does not increase the risk for dehydration, but rather indicates a higher proportion of water in relation to body weight. Percentage of body water may decrease with aging due to factors such as loss of muscle mass, increased fat tissue, or hormonal changes.
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because psychiatric history is not the most urgent assessment to make for a client who reports feeling depressed and anxious. Psychiatric history can provide valuable information about the client's diagnosis, treatment, and response, but it is not a priority over the client's safety and wellbeing.
Choice B reason: This statement is correct because suicide risk is the most urgent assessment to make for a client who reports feeling depressed and anxious. Suicide risk can indicate the client's level of hopelessness, despair, and intent to harm themselves. The nurse should assess the client's suicidal thoughts, plans, means, and access, and implement appropriate interventions to prevent self harm or suicide.
Choice C reason: This statement is incorrect because support systems are not the most urgent assessment to make for a client who reports feeling depressed and anxious. Support systems can provide emotional, social, and practical assistance to the client, but they are not a priority over the client's safety and wellbeing.
Choice D reason: This statement is incorrect because coping abilities are not the most urgent assessment to make for a client who reports feeling depressed and anxious. Coping abilities can reflect the client's strategies and skills to manage their stress and emotions, but they are not a priority over the client's safety and wellbeing.
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