A nurse is caring for a newly admitted client. Which should the nurse include in the assessment phase of the nursing process?
Identify the needed nursing actions to address the client's health problem.
Interview the client about current and past health history.
Measure the success of the care goals.
Develop the expected outcome with the client.
The Correct Answer is B
A. Identify the needed nursing actions to address the client's health problem: Planning and determining interventions occur in the planning phase, not during assessment. Assessment focuses on data collection rather than action implementation.
B. Interview the client about current and past health history: Collecting subjective and objective information through interviews, observation, and examination is the core of the assessment phase. This information forms the foundation for identifying problems and planning care.
C. Measure the success of the care goals: Evaluating whether goals have been met is part of the evaluation phase. It occurs after interventions have been implemented and outcomes are assessed.
D. Develop the expected outcome with the client: Establishing expected outcomes is part of the planning phase. It follows assessment and involves collaboration with the client to determine realistic and measurable goals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A complete assessment: During an initial home visit, a complete assessment is appropriate because the nurse needs to gather comprehensive information about the client’s medical history, current health status, medications, and environmental factors to create a thorough plan of care.
B. A follow-up assessment: Follow-up assessments are used to monitor progress or evaluate ongoing treatment. Since this is the first visit, a follow-up assessment would be premature.
C. An emergency assessment: Emergency assessments are performed when a client presents with life-threatening or urgent conditions. A routine initial home visit does not indicate an immediate threat, so this is not appropriate.
D. A rapid assessment: Rapid assessments are brief evaluations used in urgent or unstable situations to identify immediate needs. This type of assessment is not suitable for a comprehensive initial home visit.
Correct Answer is D
Explanation
A. Beneficence: Beneficence involves acting in the client’s best interest to promote well-being and prevent harm. While the provider may have attempted to ensure the client’s safety, allowing the client to leave does not exemplify beneficence because the focus was on respecting the client’s choice rather than prioritizing their safety.
B. Fidelity: Fidelity refers to maintaining loyalty, keeping promises, and being faithful to commitments made to the client. Although the provider provided information and guidance, the scenario emphasizes respect for decision-making rather than maintaining a specific promise or commitment.
C. Veracity: Veracity involves truth-telling and providing accurate, honest information. The healthcare provider did explain the risks associated with leaving, which demonstrates veracity, but the ethical principle highlighted in this situation is about the client’s right to make their own decisions.
D. Autonomy: Autonomy is the ethical principle that supports an individual’s right to make informed decisions about their own care. By respecting the client’s choice to leave despite the risks, the healthcare provider upheld the client’s autonomy.
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