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
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 D
Explanation
Choice A reason: Counteract shyness in the client is not the major effect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have different meanings and effects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to establish rapport, show interest, or convey sincerity, but it may not necessarily counteract shyness in the client. In fact, some clients may feel uncomfortable, intimidated, or threatened by too much eye contact, especially if they are shy, anxious, or from a different cultural background. Therefore, this choice is incorrect.
Choice B reason: Keep the Practical Nurse’s atention on the conversation is not the major effect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have different meanings and effects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to keep the
Practical Nurse’s atention on the conversation, but it is not the main purpose or outcome of doing so. The main purpose or outcome of maintaining eye contact is to communicate with the other person effectively and respectfully, not to focus on oneself or one’s own behavior. Therefore, this choice is incorrect.
Choice C reason: Assess if the client is involved in the conversation is not the major effect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have different meanings and effects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can help to assess if the client is involved in the conversation, but it is not the only or most reliable way of doing so. The Practical Nurse should also pay atention to other verbal and nonverbal cues from the client, such as their tone of voice, facial expressions, body language, or feedback. Therefore, this choice is incorrect.
Choice D reason: Indicate continuous focused atention is the major effect of maintaining eye contact for 2 to 6 seconds during communication. Eye contact is a nonverbal cue that involves looking at the other person’s eyes or face while communicating. It can have different meanings and effects depending on the culture, context, and relationship of the communicators. Maintaining eye contact for 2 to 6 seconds can indicate continuous focused atention, which means that the Practical Nurse is listening actively, understanding empathetically, and responding appropriately to the client’s message. It can also show respect, interest, or sincerity to the client, and enhance rapport and trust between them. Therefore, this choice is correct.
Correct Answer is B
Explanation
This is the observation that indicates that the UAPs need additional information about the turning procedure because it is incorrect and may cause complications for the client. The client who had a hip arthroplasty with prosthesis placement should not keep both legs straight and together while turning because this may cause dislocation of the prosthesis, nerve damage, or bleeding. The client should keep the affected leg slightly abducted and supported with pillows or an abduction device.
A. An abduction pillow is placed between the client's legs when positioned is correct and does not indicate a need for additional information. This helps to maintain proper alignment and prevent dislocation of the prosthesis.
C. A turning sheet used under the client for turning and repositioning is correct and does not indicate a need for additional information. This helps to reduce friction and shear forces on the skin and prevent pressure ulcers.
D. The UAPs keep their backs straight and knees bent when moving the client is correct and does not indicate a need for additional information. This helps to protect their own musculoskeletal health and prevent injuries.
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