A nurse is working with an RN to admit a new client.
Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?
Evaluation
Data collection
Implementation
Planning —
The Correct Answer is D
Choice A rationale
Evaluation is the final step of the nursing process, where the nurse determines the client's progress toward achieving the established goals and outcomes. This involves comparing the client's current status and responses to the criteria set during the planning phase, and then modifying the care plan as necessary, which occurs after goal formulation.
Choice B rationale
Data collection (Assessment) is the initial step of the nursing process, involving the systematic and continuous gathering of subjective and objective information about the client. This foundational step precedes the identification of problems and the formulation of goals, as the data collected is used to inform and drive the goals developed later in the process.
Choice C rationale
Implementation is the action phase where the nurse performs the planned interventions to achieve the established goals. This step occurs after the planning phase where the goals are formulated, as the goals provide the specific direction and purpose for the nursing actions and interventions carried out by the nurse.
Choice D rationale
Planning is the step where the nurse, in collaboration with the client and other healthcare providers, formulates realistic, client-centered goals and expected outcomes. This step uses the data from the assessment to prioritize needs and then sets specific, measurable criteria for a positive outcome, directly aligning with the scenario described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Demographic data (e.g., name, date of birth, sex, address) are fundamental identifying elements required in an electronic health record (EHR). This information is scientifically essential for correctly linking all clinical data, billing records, and legal consent forms to the unique individual, ensuring patient safety and accurate medical record identification across different healthcare encounters.
Choice B rationale
Billing payments detail the financial transactions related to care and are typically contained within the separate financial or billing system, not the clinical EHR. While the EHR documents the services provided, the record of payments received is an administrative financial detail, not a core component of the scientific clinical health record.
Choice C rationale
A Driver's license number is a form of personal identification but is not a required core component of the clinical EHR. While it might be used during registration for identity verification, its inclusion is not necessary for the scientific or legal documentation of a patient's medical history, treatment, or clinical outcomes.
Choice D rationale
Facility policies are operational and administrative documents that guide staff behavior and are housed in the organization's policy manual system. They are the rules for care, not the record of care provided to a specific patient. Their inclusion within the patient's individual EHR is inappropriate and unnecessary.
Correct Answer is C
Explanation
Choice A rationale
While delegation requires clear communication, the statement "Do not delegate" is a procedural or ethical guideline, not an example of the specific type of communication occurring during the act of delegating an outpatient procedure, which fundamentally involves a structured exchange of information and expectations.
Choice B rationale
Non-therapeutic communication includes techniques like stereotyping, challenging, or giving false reassurance, which block or hinder the development of a trusting, constructive relationship. The structured exchange needed for safe delegation, however, must be goal-directed and professional, aiming for clarity and task completion.
Choice C rationale
Therapeutic communication is a goal-directed form of professional exchange used to build rapport, obtain information, and impart instructions. When delegating a task to UAP, the nurse employs clear, structured, and goal-oriented communication to ensure the task is understood and performed safely and correctly, fitting the definition of therapeutic communication in a professional context.
Choice D rationale
Non-verbal communication (e.g., body language, facial expressions) is always part of any interaction, but it is not the main example when delegating an outpatient procedure, which primarily relies on clear, specific verbal instructions to ensure task completion and patient safety.
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