A nurse is developing pain management goals to a post-operative client. Which of the following steps of the nursing process is the nurse performing?
Planning
Assessment
Implementation
Evaluation
The Correct Answer is A
A. Planning: Developing goals is part of the planning phase, where the nurse sets objectives and outcomes for the patient’s care.
B. Assessment: Assessment involves collecting data about the patient’s condition.
C. Implementation: Implementation involves putting the care plan into action.
D. Evaluation: Evaluation involves determining whether the patient has met the goals and outcomes set during the planning phase.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Speak loudly and use simple words: Speaking loudly may be perceived as shouting and can increase agitation. Using simple words is appropriate, but volume should be normal and calm.
B. Address the client by name and reorient client: Addressing the client by name and reorienting him is effective because it respects his dignity and helps him understand his current situation, reducing confusion and agitation. This approach is clear, respectful, and supportive.
C. Challenge the client to refocus his attention when he becomes agitated: Challenging the client can be confrontational and may escalate agitation. It is better to use a calm, reassuring approach.
D. Ask the client a series of questions without allowing time for the client to answer: This can overwhelm and frustrate the client, leading to increased agitation.
Correct Answer is A
Explanation
A. The nurse determines the client’s readiness to learn: Assessing the client's readiness to learn is part of the assessment phase of the teaching plan. It involves evaluating the client’s emotional and cognitive state to ensure they are prepared to absorb new information.
B. The nurse discusses types of food that the client needs to avoid: This is part of the teaching or implementation phase, not the assessment phase.
C. The nurse describes which supplies would be needed: Describing necessary supplies is also part of the teaching or implementation phase.
D. Ask the client to demonstrate emptying of the colostomy bag: This is part of the evaluation phase, where the nurse assesses the client’s ability to perform the task taught.
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