The basis for designing and selecting nursing interventions to meet client needs is the:
Nurse’s notes
Nursing diagnosis
Doctor’s orders
Care plan
The Correct Answer is A
Choice A reason: This is incorrect because it shows that the nurse is not using a systematic and evidence-based approach to care. The nurse’s notes are a form of documentation, not a source of planning.
Choice B reason: This is correct because it shows that the nurse is using a systematic and evidence-based approach to care. The nursing diagnosis is a clinical judgment that identifies the client’s actual or potential health problems or needs and provides the basis for selecting appropriate interventions.
Choice C reason: This is incorrect because it shows that the nurse is not using a holistic and individualized approach to care. The doctor’s orders are a form of prescription, not a source of planning.
Choice D reason: This is incorrect because it shows that the nurse is confusing the outcome with the process. The care plan is a written document that outlines the goals, interventions, and evaluation of care, not a source of planning.
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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 ["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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