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 B
Explanation
Choice A reason: "There is no reason to worry. This surgeon has an excellent reputation.” is not the best nursing response. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also shows authority, which is a communication barrier that involves using one’s position or status to influence or persuade the other person. It does not address the client’s emotions or needs, and may sound patronizing or condescending. Therefore, this choice is incorrect.
Choice B reason: “It sounds as though you have mixed feelings about the surgery. Can you tell me more about how you feel?” is the best nursing response. This response shows active listening, which is a communication skill that involves hearing, understanding, and responding to the client’s verbal and nonverbal messages. It also shows empathy, which is the ability to understand and share the feelings of another person. It acknowledges and validates the client’s emotions, and invites them to express their concerns or fears. Therefore, this choice is correct.
Choice C reason: "The benefits outweigh the risks. You can be confident that the surgery should be done.” is not the best nursing response. This response shows persuasion, which is a communication technique that involves using logic or evidence to convince or influence the other person. It also shows assumption, which is a communication barrier that involves making judgments or guesses about what the other person thinks or feels. It does not address the client’s emotions or needs, and may sound coercive or manipulative. Therefore, this choice is incorrect.
Choice D reason: "You are bound to feel much beter once it is all over with.” is not the best nursing response. This response shows cliché, which is a communication technique that involves using overused or trite expressions that lack meaning or sincerity. It also shows avoidance, which is a communication barrier that involves shifting the focus away from the other person’s feelings or situation. It does not address the client’s emotions or needs, and may sound vague or insincere. Therefore, this choice is incorrect.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because it shows that the problem is not suspected, but rather the client has a desire to improve or maintain a level of health. A wellness nursing diagnosis describes a potential or actual health state that can be enhanced.
Choice B reason: This is incorrect because it shows that the problem is not suspected, but rather the client has a cluster of related problems that are associated with a specific situation or event. A syndrome nursing diagnosis describes a patern of responses that are linked by a common cause.
Choice C reason: This is correct because it shows that the problem is suspected, but lacks enough data to support it. A ‘risk for’ nursing diagnosis describes a potential problem that may occur if certain risk factors are present.
Choice D reason: This is incorrect because it shows that the problem is not suspected, but rather the client has signs and symptoms that indicate an actual health issue. An actual nursing diagnosis describes a current problem that has been validated by data.
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