A nurse is developing a care plan for a client who has impaired mobility due to a stroke. Which of the following actions should the nurse take first when formulating a diagnostic statement?

Choice A reason:

Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.

Choice B reason:

Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.

Choice C reason:

Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.

Choice D reason:

Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.

Choice E reason:

Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.

Choice A:

Compare the data with normal standards and ranges. This is a valid action for the nurse to take, because it helps to identify any abnormal findings or deviations from the expected values. For example, the nurse can compare the client's blood pressure, pulse, and temperature with the normal ranges for adults.

Choice B:

Use open-ended questions to clarify the data. This is also a valid action for the nurse to take, because it allows the client to provide more information and elaborate on their responses. Open-ended questions are those that cannot be answered with a simple yes or no, such as "How do you feel about your condition?.”. or "What are your main concerns?.".

Choice C:

Repeat the assessment using a different method or source. This is another valid action for the nurse to take, because it helps to confirm the accuracy and reliability of the data. For example, the nurse can use a different device to measure the blood pressure, ask another health care professional to verify the findings, or check the client's medical records for previous data.

Choice D:

All of the above. This is the correct answer, because all of the actions listed above are appropriate ways for the nurse to validate the data collected from an assessment of a client who has hypertension. Validation is an important step in the assessment process, because it ensures that the data are complete, accurate, and consistent.