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. Provide the client with a towel and tell the client the nurse will assist her when he/she is finished administering the tube feeding B. Stop administering the tube feeding and assist the client who spilled coﬀee with changing her wet clothing and C. assess for burns D. Request a replacement tray and assist the client with changing her wet clothing

Correct Answer is ["B"]

Explanation

Choice A reason: This is incorrect because it shows a lack of empathy and priority for the client who spilled coﬀee. The nurse should not delay providing care for a client who may have suﬀered a burn.

Choice B reason: This is correct because it shows that the nurse prioritizes the safety and comfort of the client who spilled coﬀee. The nurse should stop the tube feeding and assess for burns, which can be a serious complication.

Choice C reason: This is incorrect because it does not address the potential burn injury of the client who spilled coﬀee. The nurse should not focus on replacing the tray before assessing for burns.

Choice D reason: This is correct because it shows that the nurse delegates appropriately and ensures that both clients receive timely care. The nurse should stop the tube feeding and request another nurse to assist the client who spilled coﬀee.

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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

A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coﬀee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)

Correct Answer is ["B"]

Explanation

The basis for designing and selecting nursing interventions to meet client needs is the:

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