A nurse is preparing a client for a colonoscopy.

The client has a family history of colon cancer.

Which of the following types of prevention is the nurse demonstrating?

Choice A rationale

The outcome identification and planning step of the nursing process is specifically designed to develop a personalized plan of care. This involve setting realistic, measurable, and client-centered goals based on the identified nursing diagnoses. By collaborating with the client, the nurse ensures that the interventions are acceptable to the individual and tailored to their specific needs. This stage serves as a roadmap for the implementation phase, providing clear direction for all members of the healthcare team.

Choice B rationale

Collecting and analyzing data to establish a database is the primary purpose of the Assessment phase, which is the first step of the nursing process. During assessment, the nurse gathers subjective and objective information through interviews, physical examinations, and review of medical records. This data collection is essential for identifying the client's health status, but it occurs before the planning phase, as the plan cannot be formulated without a comprehensive understanding of the patient's baseline.

Choice C rationale

Interpreting and analyzing data to identify health problems and risks is the hallmark of the Nursing Diagnosis phase. This is the second step of the nursing process, where the nurse uses clinical reasoning to determine the client's response to actual or potential health conditions. While this phase is critical for informing the plan of care, the primary goal of the planning phase itself is the subsequent development of goals and strategies to address those diagnosed problems.

Choice D rationale

Writing client-centered nursing diagnoses is the output of the Nursing Diagnosis phase, not the Planning phase. A nursing diagnosis is a clinical judgment about the individual, family, or community. Once these diagnoses are established, the nurse then moves into the Outcome Identification and Planning phase to determine how to resolve or manage those specific issues. Planning relies on the accuracy of the diagnoses to ensure that the goals set are relevant to the client's actual health needs.

Choice A rationale

Cognitive outcomes involve the acquisition of knowledge, intellectual skills, and the comprehension of information. While the client needs to understand why the fistula is important, the specific outcome of "demonstrating care" implies a physical action rather than just a mental grasp of concepts. If the outcome was "Client will explain the purpose of the fistula," it would be cognitive. However, the focus here is on the manual execution of care tasks for the access site.

Choice B rationale

Affective outcomes relate to changes in attitudes, values, and feelings. This domain would be addressed if the goal was for the client to express a positive attitude toward his treatment or to accept the changes in his body image due to the presence of the arteriovenous fistula. While emotional adjustment is crucial for chronic renal failure patients, the phrase "demonstrate the appropriate care" specifically targets the physical ability to maintain the site, not an emotional or value-based response.

Choice C rationale

The psychomotor domain involves the integration of mental and physical activity to perform a manual task or motor skill. Demonstrating the care of an arteriovenous fistula requires the client to physically perform actions such as palpating for a thrill, listening for a bruit, and keeping the site clean and protected. These are technical skills that must be practiced and mastered. Therefore, this outcome is scientifically classified as psychomotor because it measures the client's ability to perform a physical procedure.

Choice D rationale

Holistic outcomes refer to an approach that considers the whole person, including physical, emotional, social, and spiritual dimensions. While nursing care is holistic in its overall philosophy, specific educational outcomes are categorized into the three distinct domains of learning: cognitive, affective, and psychomotor. Classifying an outcome as holistic is too broad for clinical measurement. In the context of learning objectives, the specific requirement to "demonstrate care" fits the definition of a motor skill within the psychomotor domain.