A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:
use a Nursing Diagnosis from a source other than NANDA-I
limit the number of interventions
select interventions which will be easy to implement
involve the patient in the process
The Correct Answer is D
A. Use a Nursing Diagnosis from a source other than NANDA-I: NANDA-I provides standardized nursing diagnoses that ensure accurate problem identification and care planning.
B. Limit the number of interventions: Interventions should be appropriate and sufficient rather than arbitrarily limited.
C. Select interventions which will be easy to implement: Interventions should be effective and individualized, not just easy.
D. Involve the patient in the process: Patient involvement ensures better adherence, understanding, and personalized care.
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Related Questions
Correct Answer is B
Explanation
A. Validated data: While accurate data is crucial, validated data alone does not form a nursing diagnosis.
B. Data clustering: Data clustering involves grouping related signs, symptoms, and risk factors to determine patterns that lead to a nursing diagnosis.
C. Subjective data: Subjective data (e.g., pain, nausea) is part of assessment but must be combined with objective data to establish a diagnosis.
D. Objective data: Objective data (e.g., lab results, physical exam findings) is important, but a nursing diagnosis requires a comprehensive approach, including data clustering.
Correct Answer is C
Explanation
A. Implementation: Implementation occurs after interventions have been planned and involves carrying out those interventions.
B. Evaluation: Evaluation occurs after implementation to assess if the intervention was effective.
C. Planning: The planning phase involves choosing the best interventions based on patient assessment and nursing diagnosis.
D. Assessment: Assessment is gathering information about the patient, not deciding on interventions.
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