A nurse performs an initial interview for a client who presents with manifestations consistent with Parkinson's disease. The nurse also interviews the client's family. Which of the following steps of the nursing process is the nurse completing?
Planning
Diagnosis
Evaluation
Assessment
The Correct Answer is D
A. The planning step involves developing goals, expected outcomes, and interventions based on the identified nursing diagnoses. It occurs after data collection, not during the initial interview.
B. The diagnosis step requires the nurse to analyze assessment data to identify actual or potential health problems. The nurse cannot make a diagnosis until all relevant information has been gathered.
C. Evaluation occurs after interventions are implemented and focuses on determining whether the client’s goals and outcomes have been met. It does not apply to an initial interview situation.
D. This is the first step of the nursing process, in which the nurse collects and organizes data about the client’s physical, psychological, and social status. Interviewing the client and family to gather information about symptoms, history, and behaviors is part of the assessment phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Standards of practice specify that nurses must provide care that reflects current, evidence-based practice and demonstrate a competent level of behavior when delivering client care. These standards guide safe, effective, and ethical nursing practice.
B. A list of skills that all nurses should be competent performing describes scope of practice, which outlines the roles and responsibilities of nurses, not the standards of practice itself.
C. Competencies required before licensure refer to entry-level requirements for becoming a licensed nurse, rather than ongoing standards of practice.
D. Protocols for specific health problems are organizational or clinical guidelines, not the overarching standards that define professional nursing practice.
Correct Answer is ["A","C","D"]
Explanation
A. This is objective data because it is measurable and observable using equipment, not dependent on the client’s perception.
B. This is subjective data, as it is based on the client’s personal experience and cannot be directly observed or measured by the nurse.
C. This is objective data, since swelling and warmth are observable and measurable physical findings detected through inspection and palpation.
D. This is objective data, as it is quantifiable information obtained through measurement of urine output.
E. This is subjective data, because pain is a personal and self-reported sensation that cannot be directly measured by the nurse.
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