A nurse is reassessing a client before performing an intervention for a client who has hypertension. Which of the following are essential components of this skill? (Select all that apply.).

Choice A reason:.

Establishing a baseline for planning care and evaluating outcomes is the main purpose of the assessment phase of the nursing process. The assessment phase involves collecting data about the client's health status and needs, which will help the nurse to identify any problems or potential problems that may need to be addressed. The assessment data will also serve as a reference point for comparing the client's progress and outcomes throughout the nursing process.

Choice B reason:.

Identifying the client's response to health concerns or illness is part of the diagnosis phase of the nursing process. The diagnosis phase involves analyzing the data collected during the assessment phase and identifying the client's problems and strengths. The nurse then formulates a nursing diagnosis, which is a statement of the client's actual or potential health problem that can be addressed by nursing interventions.

Choice C reason:.

Providing goal-directed, client-centered care is part of the planning and implementation phases of the nursing process. The planning phase involves setting goals and outcomes for the client and selecting appropriate interventions to achieve them. The goals and outcomes should be specific, measurable, attainable, realistic, and timely (SMART), and they should reflect the client's preferences and values. The implementation phase involves carrying out the interventions and documenting the actions and responses. The interventions should be evidence-based, safe, and effective, and they should involve the client as much as possible.

Choice D reason:.

Comparing the client's data with expected standards or reference ranges is part of the evaluation phase of the nursing process. The evaluation phase involves evaluating the effectiveness of the interventions and modifying the plan as needed. The nurse compares the client's actual outcomes with the expected outcomes and determines whether the goals have been met, partially met, or not met. The nurse also identifies any factors that may have influenced the outcomes, such as client compliance, environmental factors, or unexpected events.

Choice A reason:

The nurse uses a mechanical lift to transfer the client from bed to chair. This is the correct answer because it demonstrates the use of appropriate resources and equipment to prevent injury to the client and the nurse, and to facilitate safe mobility for the client who has impaired mobility due to a stroke. A mechanical lift is a device that helps lift and move a person who cannot move on their own or with minimal assistance.

Choice B reason:

The nurse performs passive range of motion exercises for the affected limbs. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps maintain joint mobility, prevent contractures, and improve circulation for the client who has impaired mobility due to a stroke. Passive range of motion exercises are movements that are done by someone else for a person who cannot move their own limbs.

Choice C reason:.

The nurse encourages the client to participate in physical therapy sessions. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps promote recovery, prevent complications, and improve function for the client who has impaired mobility due to a stroke. Physical therapy is a type of rehabilitation that involves exercises and activities that help improve strength, balance, coordination, and mobility.

Choice D reason:

The nurse applies antiembolic stockings and sequential compression devices to the lower extremities. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps prevent deep vein thrombosis (DVT), a potential complication of stroke that occurs when a blood clot forms in a vein deep in the body. Antiembolic stockings are tight-fitting elastic socks that apply pressure to the legs and feet to improve blood flow and prevent clotting. Sequential compression devices are inflatable sleeves that wrap around the legs and inflate and deflate periodically to squeeze the veins and improve blood flow.