A nurse is caring for a client and notes that the client appears disheveled and frightened and seems to be talking to someone who is not there. The nurse should identify that this is an example of which of the following steps of the nursing process?
Evaluation
Planning
Analysis
Data collection
The Correct Answer is D
A. The evaluation phase occurs after interventions have been implemented to determine whether the client’s condition or behavior has improved and if the goals of care were met. In this scenario, the nurse has not yet implemented or reviewed interventions, so evaluation is not applicable.
B. The planning phase involves developing goals and selecting nursing interventions to address identified problems. The nurse must first gather and interpret data before formulating an appropriate plan of care.
C. The analysis (or diagnosis) phase follows data collection and involves interpreting the collected data to identify the client’s health problems or nursing diagnoses. While the nurse might later analyze these findings to identify psychotic symptoms, that step occurs after the initial data are collected.
D. Observing that the client is disheveled, frightened, and talking to someone who is not there represents objective data collection — part of the assessment phase of the nursing process. The nurse is gathering observable information about the client’s appearance and behavior, which are essential to understanding their current mental status and forming an accurate nursing diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This demonstrates beneficence, which means doing good and acting in the best interest of the client. By providing pain relief, the nurse is actively promoting the client’s comfort and well-being.
B. This illustrates autonomy, as it supports the client’s right to make informed decisions about their own care.
C. This demonstrates fidelity, the ethical principle of keeping promises and commitments made to clients.
D. This reflects justice, which involves fair and equal treatment of all clients without bias.
Correct Answer is C
Explanation
A. Environmental factors involve physical surroundings that affect health, such as pollution, unsafe living conditions, or lack of clean water. While subsidized housing is an environmental condition, the client’s concern is about affording medication, which relates more directly to finances.
B. Cultural factors include beliefs, values, and practices that influence health behaviors and decision-making. The client’s concern is not related to cultural beliefs but to financial limitations.
C. Socioeconomic factors involve income level, employment status, education, and access to resources that influence a person’s ability to maintain health. The client’s worry about paying for medications reflects a financial barrier, making this a socioeconomic factor affecting health.
D. Health literacy refers to a client’s ability to obtain, process, and understand health information needed to make appropriate decisions. The client’s concern is not about understanding medication instructions but about being able to afford them.
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