A nursing student in clinical asks her instructor what the primary purpose of nursing diagnoses is?
What is the appropriate response by the instructor?
Mutually establish desired outcomes of the plan of care
Guide selection of nursing interventions to meet expected outcomes
Establish a database of information for future comparison
Evaluate the effectiveness of the established plan of care
The Correct Answer is B
A. Mutually establish desired outcomes of the plan of care:
While establishing desired outcomes is an important part of the nursing process, nursing diagnoses themselves do not necessarily focus on mutually establishing these outcomes. Nursing diagnoses help identify health problems and needs, which then guide the development of outcomes during the planning phase.
B. Guide selection of nursing interventions to meet expected outcomes:
This is the correct answer. Nursing diagnoses help determine the specific needs and problems a patient is facing. Once identified, nursing interventions can be chosen to address these needs and work towards achieving expected outcomes.
C. Establish a database of information for future comparison:
Establishing a database of information is more related to the assessment phase of the nursing process. Nursing diagnoses are formulated based on the analysis of the collected data and serve to guide subsequent steps in the nursing process, particularly planning and intervention.
D. Evaluate the effectiveness of the established plan of care:
Evaluating the effectiveness of the established plan of care is part of the later stages of the nursing process. Nursing diagnoses help in planning and implementing interventions, and evaluating their effectiveness comes after these interventions have been carried out.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ask the client if she is having pain.
This option recognizes the potential relationship between pain and elevated blood pressure. Assessing the client for pain is crucial, as pain can contribute to increased blood pressure.
B. Request a prescription for an antianxiety medication.
This option assumes that anxiety might be the cause of the elevated blood pressure. However, without further assessment, it may not be appropriate to jump to prescribing medication for anxiety.
C. Request a prescription for an antihypertensive medication.
Initiating antihypertensive medication without further assessment may not be the most appropriate first step, especially if the elevated blood pressure is related to pain or another temporary factor.
D. Return in 30 minutes to recheck the client’s blood pressure.
While monitoring blood pressure is important, waiting 30 minutes without further assessment or intervention might delay addressing the underlying issue, especially if it is related to pain or another acute problem.
Correct Answer is A
Explanation
A. The client:
The client is the most reliable source of information about their own health. Direct communication with the client allows the nurse to gather details about their symptoms, medical history, current health status, and any other relevant information. This is crucial for accurate assessment and care planning.
B. Progress note:
Progress notes are documentation by healthcare providers that summarize the client's clinical status, interventions, and responses to care. While progress notes can provide valuable information, they are not always as up-to-date as direct communication with the client.
C. Medical history:
The medical history contains information about the client's past health conditions, treatments, and surgeries. While important, medical history may not capture the most recent or current information, especially if there have been recent changes in the client's health.
D. Family information:
Family information can provide additional context, support, and insights into the client's health. However, it may not always be as accurate or comprehensive as the information obtained directly from the client. Family members may not be aware of recent changes or may have different perspectives on the client's health.
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