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

Choice A reason: Implementation is a phase 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. The nurse’s actions do not reflect this phase, as they are not performing any interventions or activities, but rather observing and measuring the client’s condition. Therefore, this choice is incorrect.

Choice B reason: Evaluation is a phase of the nursing process that involves measuring the outcomes and determining whether the interventions were effective in resolving or preventing the problem. It also involves comparing the actual outcomes with the expected outcomes, and modifying the plan of care if needed. The nurse’s actions reflect this phase, as they are assessing the client’s leg for signs of improvement or resolution of thrombophlebitis, and noting that the client is ready for discharge. Therefore, this choice is correct.

Choice C reason: Outcomes identification is a phase 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. The nurse’s actions do not reflect this phase, as they are not setting any goals, but rather evaluating whether they have been met.

Therefore, this choice is incorrect.

Choice D reason: Assessment is a phase of the nursing process that involves collecting and analyzing data about the client’s health status, history, and environment. It also involves identifying any factors that may affect the client’s health or well-being, and forming a nursing diagnosis. The nurse’s actions do not reflect this phase, as they are not collecting or analyzing any new data, but rather reviewing the existing data and confirming the diagnosis. Therefore, this choice is incorrect.

Choice A reason: Speaks in a normal tone is an approach that can best facilitate communication with a client who is hearing-impaired. Speaking in a normal tone can help the client to hear the natural variations and inflections of the voice, and to avoid distortion or confusion. Speaking in a high-pitched or low-pitched tone can make the voice harder to hear or understand, especially if the client has a hearing loss in a specific frequency range. Therefore, this choice is correct.

Choice B reason: Speaks frequently is not an approach that can best facilitate communication with a client who is hearing-impaired. Speaking frequently can overwhelm or fatigue the client, and reduce their ability to process or retain the information. Speaking frequently can also interrupt the client’s thoughts or responses, and prevent them from expressing their needs or concerns. Speaking clearly and concisely, and allowing pauses or breaks, can enhance communication with a client who is hearing-impaired. Therefore, this choice is incorrect.

Choice C reason: Speaks directly into the unaffected ear is not an approach that can best facilitate communication with a client who is hearing-impaired. Speaking directly into the unaffected ear can create an uncomfortable or unnatural position for the client and the nurse, and interfere with eye contact or facial expressions. Speaking directly into the unaffected ear can also create a loud or distorted sound that may be unpleasant or painful for the client.

Speaking face-to-face, and slightly toward the unaffected ear, can improve communication with a client who is hearing-impaired. Therefore, this choice is incorrect.

Choice D reason: Speaks in a normal volume is an approach that can best facilitate communication with a client who is hearing-impaired. Speaking in a normal volume can help the client to hear the voice without difficulty or strain, and to avoid embarrassment or irritation. Speaking in a loud volume can make the voice harder to hear or understand, as it can cause background noise, echo, or feedback. Speaking in a loud volume can also imply shouting or anger, which can be disrespectful or offensive to the client. Therefore, this choice is correct.