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 symptoms are subjective or objective manifestations of a health problem that are perceived or reported by the client.

Choice B reason: This is incorrect because urinary retention is a specific condition that involves the inability to empty the bladder completely, which is not related to the data presented.

Choice C reason: This is incorrect because signs of ﬂuid overload are opposite to the data presented, such as edema, weight gain, crackles in the lungs, and distended neck veins.

Choice D reason: This is incorrect because data clustering is a process of grouping related data together to identify paterns and potential problems, not a type of data itself.

A. Insufficient knowledge B. Pupils round, reactive to light and accommodation C. Pain D. Impaired gas exchange

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: This is correct because it is an approved nursing diagnosis that describes a lack of cognitive information related to a specific topic.

Choice B reason: This is incorrect because it is not an approved nursing diagnosis, but rather a data or assessment finding that describes the condition of the client’s pupils.

Choice C reason: This is correct because it is an approved nursing diagnosis that describes an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Choice D reason: This is correct because it is an approved nursing diagnosis that describes a decrease in oxygenation and/or elimination of carbon dioxide at the alveolar-capillary membrane.

Choice E reason: This is incorrect because it is not an approved nursing diagnosis, but rather a medical diagnosis that describes a malignant neoplasm of any body part.

Choice F reason: This is incorrect because it is not an approved nursing diagnosis, but rather a medical diagnosis that describes a dysfunction of the kidneys.

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

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Naxlex Comprehensive Predictor Exams

During a physical examination, the Practical Nurse (PN) discovers that the client demonstrates signs of ﬂushed, dry, hot skin; dry oral mucus membranes; and temperature elevation. The PN will treat these data as the basis of a nursing diagnosis plan, as they represent:

Correct Answer is A

Explanation

Which of the following are approved nursing diagnoses? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

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

A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

What should the nurse do with linens that have been soiled by a client with hepatitis?

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

A female client who is experiencing disordered thinking about food being poisoned is admited to the mental health unit. The nurse should use which communication technique to encourage the client to eat dinner? Select one answer