A nurse is developing a plan of care for a client who has diabetes mellitus. Which of the following actions should the nurse take first?

Consult with other members of the health care team.

Involve the client in decision making.

Review current literature on diabetes management.

Identify realistic and measurable outcomes.

Answer and Explanation

The Correct Answer is B

Choice A reason:

Consulting with other members of the health care team is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While collaboration is important, the nurse should first involve the client in decision making to ensure that the plan of care is individualized, realistic and acceptable to the client.

Choice B reason:

Involve the client in decision making is the correct answer. This is the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. Involving the client in decision making promotes self-management, adherence and empowerment. The client is the best source of information about their preferences, goals and needs.

Choice C reason:

Reviewing current literature on diabetes management is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While evidence-based practice is essential, the nurse should first involve the client in decision making to ensure that the plan of care is based on the client's situation and values.

Choice D reason:

Identifying realistic and measurable outcomes is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While outcome identification is a key step in the nursing process, the nurse should first involve the client in decision making to ensure that the outcomes are relevant and achievable for the client.

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Correct Answer is ["A","B","C","E"]

Explanation

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.

A. "It involves determining the effectiveness of nursing interventions.”. B. "It involves establishing priorities and measurable outcomes.”. C. "It involves identifying gaps between actual and expected findings.”. D. "It involves selecting appropriate evidence-based interventions.".

Correct Answer is A

Explanation

Choice A reason:

It involves determining the effectiveness of nursing interventions. This is the correct definition of the evaluation phase of the nursing process, which is the final step where the nurse compares the actual outcomes with the expected outcomes and modifies the plan of care if needed.

Choice B reason:

It involves establishing priorities and measurable outcomes. This is not the correct definition of the evaluation phase, but rather the planning phase of the nursing process, which is the third step where the nurse identifies client goals and interventions based on the nursing diagnosis.

Choice C reason:

It involves identifying gaps between actual and expected findings. This is not the correct definition of the evaluation phase, but rather a component of it. Identifying gaps between actual and expected findings is one way to determine the effectiveness of nursing interventions, but it is not the only way. The evaluation phase also involves documenting and communicating the results of the evaluation.

Choice D reason:

It involves selecting appropriate evidence-based interventions. This is not the correct definition of the evaluation phase, but rather another component of the planning phase of the nursing process, which is the third step where the nurse identifies client goals and interventions based on the nursing diagnosis.

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A nurse is developing a plan of care for a client who has diabetes mellitus. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using critical thinking skills to analyze data during the assessment phase of the nursing process. Which of the following actions should the nurse take?(Select all that apply).

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is reviewing the steps of the nursing process with a group of nursing students. Which of the following statements by one of the students indicates an understanding of the evaluation phase?

Correct Answer is A

Explanation

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