A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome?
Assessment
Evaluation
implementation
Planning
The Correct Answer is D
A. Assessment involves collecting and analyzing data about the client's health status, including their medical history, physical examination findings, and any other relevant information. This step is crucial for understanding the client's current condition and needs, but it precedes goal setting.
B. Evaluation is the step where the nurse determines whether the goals and outcomes established in the planning phase have been achieved. It involves assessing the effectiveness of interventions and making adjustments as needed. Evaluation occurs after goals have been set and interventions have been implemented, so it is not the step where goals are initially formulated.
C. Implementation involves carrying out the interventions and actions planned to achieve the goals established for the client. This step follows the formulation of goals and involves executing the planned care. While critical to achieving positive outcomes, implementation does not include the initial formulation of goals.
D. Planning is the step of the nursing process where the nurse formulates goals and develops a plan of care based on the assessment data. This includes setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided and achieve positive client outcomes. Planning is where goals are established to address the client’s identified needs and guide subsequent interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Monitoring blood glucose is crucial for managing diabetes, as it directly affects the child's blood sugar levels and overall well-being. However, if the child’s blood glucose levels are stable and there are no immediate concerns or symptoms, this task, while important, may not be as urgent as assessing more critically ill clients.
B. While discharge instructions are important for ensuring proper care after leaving the hospital, this task generally does not require immediate attention compared to assessing a client with more acute or urgent needs. The adolescent is ready for discharge, indicating their condition is stable enough to prepare for leaving the unit.
C. Feeding a toddler who has both arms in casts is important for ensuring that the child is well-nourished and comfortable. However, this task can usually be managed by assistive personnel or done at a scheduled time without immediate urgency compared to more critical assessments.
D. An infant with pertussis (whooping cough) receiving oxygen via nasal cannula is in a potentially critical situation. Pertussis can cause significant respiratory distress, and the need for oxygen indicates the
infant’s respiratory function is compromised. Assessing this infant first is crucial to ensure that the oxygen therapy is effective and to monitor for any signs of deterioration in respiratory status.
Correct Answer is D
Explanation
A. While it might seem like a hands-off approach, allowing the conflict to escalate without intervention can lead to further problems, affecting patient care and team morale.
B. This approach is likely to escalate the situation and is not constructive for conflict resolution. It's important to address the issue professionally and respectfully.
C. While reporting the issue might be necessary if the conflict escalates or impacts patient care, it's not the initial step. Addressing the issue directly can often resolve the conflict without involving higher management.
D. This is the most appropriate action. By addressing the issue directly, the nurse can help the APs understand each other's perspectives, find a solution, and prevent similar conflicts in the future.
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