In what step of the nursing process do the client and the nurse develop the goals? (Select all that apply)

Identify outcomes

Planning

A “risk for” nursing diagnosis

Implementation

Answer and Explanation

Correct Answer : A

Choice A reason: Identify outcomes is a step of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. Therefore, this choice is correct.

Choice B reason: Planning is a step of the nursing process that involves designing a plan of care that outlines the interventions and activities that will help the client achieve the desired outcomes. The plan of care is also developed in collaboration with the client and the nurse, and it reﬂects the client’s priorities and resources. Therefore, this choice is correct.

Choice C reason: A “risk for” nursing diagnosis is a type of nursing diagnosis that identifies a potential problem or complication that the client may develop if preventive measures are not taken. It is not a step of the nursing process,

but rather a component of the assessment step, which involves collecting and analyzing data about the client’s health status. Therefore, this choice is incorrect.

Choice D reason: Implementation is a step of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. It is not a step where the goals are developed, but rather where they are executed. Therefore, this choice is incorrect.

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Correct Answer is ["A"]

Explanation

Choice A reason: This is correct because it shows that the nurse is engaged and focused on the patient. Leaning slightly forward indicates that the nurse is listening and caring.

Choice B reason: This is correct because it shows that the nurse is open and receptive to the patient’s feelings and concerns. An open posture means that the nurse does not cross arms or legs, which can be seen as defensive or closed.

Choice C reason: This is incorrect because it shows that the nurse is distant and distracted from the patient. Standing at the doorway implies that the nurse is ready to leave or has other priorities. Reading the chart while smiling may seem insincere or superficial.

Choice D reason: This is correct because it shows that the nurse is respectful and atentive to the patient. Sitting at the bedside and facing the patient indicates that the nurse is giving eye contact and acknowledging the patient’s

presence.

A. Client’s problem B. Care plan C. Evaluation D. Assessment

Correct Answer is ["D"]

Explanation

Choice A reason: Needs medical intervention is not the major diﬀerence between the two diagnoses. Both diagnoses may require medical intervention, depending on the severity and cause of the vomiting and the nutritional deficiency. Medical intervention is not a criterion for distinguishing between diﬀerent types of nursing diagnoses.

Therefore, this choice is incorrect.

Choice B reason: Needs no defined nursing interventions is not the major diﬀerence between the two diagnoses. Both diagnoses need defined nursing interventions, such as monitoring, teaching, counseling, or providing ﬂuids and electrolytes. Nursing interventions are essential for addressing any nursing diagnosis, whether actual or potential.

Therefore, this choice is incorrect.

Choice C reason: Will not need to be evaluated is not the major diﬀerence between the two diagnoses. Both diagnoses need to be evaluated, which involves measuring the outcomes and determining whether the interventions were eﬀective in resolving or preventing the problem. Evaluation is a vital step of the nursing process for any nursing diagnosis, whether actual or potential. Therefore, this choice is incorrect.

Choice D reason: Reﬂects a problem that does not yet exist is the major diﬀerence between the two diagnoses. Diagnosis #1 is an actual nursing diagnosis, which reﬂects a problem that exists at the present time and has signs and symptoms that can be observed or measured. Diagnosis #2 is a risk for nursing diagnosis, which reﬂects a problem that does not exist at the present time but may develop in the future if preventive measures are not taken.

Therefore, this choice is correct.

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In what step of the nursing process do the client and the nurse develop the goals? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following types of posture is best for the nurse to use when communicating with the patient? (Select all that apply)

Correct Answer is ["A"]

Explanation

The Practical Nurse (PN) uses the “risk for” nursing diagnoses as identified from the: Select all that apply

Correct Answer is ["D"]

Explanation

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