Although the client denies pain, the Practical Nurse (PN) observes the client is breathing rapidly with clenched fists and is grimacing. The PN’s best response to his observations would be: * Select one answer

Choice A reason: This is incorrect because it shows that the nurse is not using a systematic and evidence-based approach to care. The nurse’s notes are a form of documentation, not a source of planning.

Choice B reason: This is correct because it shows that the nurse is using a systematic and evidence-based approach to care. The nursing diagnosis is a clinical judgment that identifies the client’s actual or potential health problems or needs and provides the basis for selecting appropriate interventions.

Choice C reason: This is incorrect because it shows that the nurse is not using a holistic and individualized approach to care. The doctor’s orders are a form of prescription, not a source of planning.

Choice D reason: This is incorrect because it shows that the nurse is confusing the outcome with the process. The care plan is a written document that outlines the goals, interventions, and evaluation of care, not a source of planning.

Choice A reason: Series of assessments that isolate a client’s health problem is not the best definition of the nursing process. The nursing process is not only a series of assessments, but also a series of actions that include planning, implementing, and evaluating the nursing care. The nursing process does not isolate a client’s health problem, but rather identifies and addresses the client’s holistic needs and responses to health and illness. Therefore, this choice is incorrect.

Choice B reason: Framework for the organization of individualized nursing care is the best definition of the nursing process. The nursing process is a framework that guides the nurse’s decision making and actions in providing individualized nursing care to each client. It involves five steps: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. It is based on scientific principles, ethical standards, and evidence-based practice. Therefore, this choice is correct.

Choice C reason: Preset formula for the design of nursing care is not the best definition of the nursing process. The nursing process is not a preset formula, but rather a dynamic and flexible method that adapts to the changing needs and situations of each client. It requires critical thinking, creativity, and clinical judgment from the nurse. It also involves collaboration and communication with the client and other members of the health care team. Therefore, this choice is incorrect.

Choice D reason: Method to assure that the physician’s orders are carried out correctly is not the best definition of the nursing process. The nursing process is not a method to assure that the physician’s orders are carried out correctly, but rather a method to provide independent and autonomous nursing care that complements or supplements the medical care. The nursing process reflects the nurse’s scope of practice, responsibility, and accountability for the client’s well-being. It also empowers the client to participate in their own care and achieve their health goals. Therefore, this choice is incorrect.