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.
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Related Questions
Correct Answer is C
Explanation
A. A client with dementia is considered legally incompetent to provide informed consent if they lack decision-making capacity. Advance directives express the client’s wishes but do not authorize consent for specific procedures once the client is incapacitated.
B. Being a primary caregiver does not automatically grant legal authority to sign consent forms unless she is designated as the legal representative or health care proxy.
C. A durable power of attorney for health care designates a legal decision-maker authorized to give informed consent on behalf of the client when they are unable to do so.
D. Assisting with finances does not grant legal authority to make medical decisions unless the sister is specifically named in a health care proxy or power of attorney document.
Correct Answer is D
Explanation
A. While the crash cart is essential for advanced resuscitation, starting chest compressions takes priority. The nurse should begin CPR immediately while another team member retrieves the cart.
B. Ventilation is important, but chest compressions should be initiated first to maintain circulation and perfusion. Once compressions are underway, airway and breathing support can follow according to the CAB (Circulation, Airway, Breathing) sequence of Basic Life Support (BLS).
C. Attaching the AED is a crucial step, but it should occur after or while chest compressions are in progress, as delays in compressions reduce the chances of survival.
D. This is the first action the nurse should take after confirming unresponsiveness and calling for help. Immediate, high-quality compressions restore blood flow to vital organs and are the priority intervention in cardiac arrest management.
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