In what step of the nursing process do the client and the nurse develop the goals? (Select all that apply)

Identify outcomes

Planning

A “risk for” nursing diagnosis

Implementation

Answer and Explanation

Correct Answer : A

Choice A reason: Identify outcomes is a step of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. Therefore, this choice is correct.

Choice B reason: Planning is a step of the nursing process that involves designing a plan of care that outlines the interventions and activities that will help the client achieve the desired outcomes. The plan of care is also developed in collaboration with the client and the nurse, and it reﬂects the client’s priorities and resources. Therefore, this choice is correct.

Choice C reason: A “risk for” nursing diagnosis is a type of nursing diagnosis that identifies a potential problem or complication that the client may develop if preventive measures are not taken. It is not a step of the nursing process,

but rather a component of the assessment step, which involves collecting and analyzing data about the client’s health status. Therefore, this choice is incorrect.

Choice D reason: Implementation is a step of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. It is not a step where the goals are developed, but rather where they are executed. Therefore, this choice is incorrect.

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Correct Answer is A

Explanation

Choice A reason: This is correct because it shows that the nurse is respectful and sensitive to the client’s language and cultural needs. Speaking slowly and providing examples can help the client comprehend and retain the information.

Choice B reason: This is incorrect because it shows that the nurse is overwhelming and insensitive to the client’s language and cultural needs. Giving too much information or using complex terms can confuse and frustrate the client.

Choice C reason: This is incorrect because it shows that the nurse is assuming and delegating the responsibility of communication to someone else. Getting an interpreter or a family member may not be necessary or appropriate if the client speaks English. The nurse should communicate directly with the client as much as possible.

Choice D reason: This is incorrect because it shows that the nurse is rude and disrespectful to the client’s language and cultural needs. Speaking quickly and avoiding eye contact can make the client feel ignored or intimidated. The nurse should maintain eye contact and speak at a normal pace.

A. Closed inquiry B. Open-ended question C. Minimal encouraging D. Restating

Correct Answer is B

Explanation

Choice A reason: This is incorrect because it shows that the PN is not using a technique that encourages the client to express feelings and thoughts. A closed inquiry is a question that can be answered with a yes or no, or a short factual response.

Choice B reason: This is correct because it shows that the PN is using a technique that encourages the client to express feelings and thoughts. An open-ended question is a question that requires more than a yes or no, or a short factual response and invites the client to elaborate.

Choice C reason: This is incorrect because it shows that the PN is not using a technique that involves asking a question. Minimal encouraging is a verbal or nonverbal response that shows interest and attention and prompts the client to continue talking.

Choice D reason: This is incorrect because it shows that the PN is not using a technique that involves asking a question. A restating is a verbal response that repeats the main idea or keywords of the client’s message and confirms understanding.

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In what step of the nursing process do the client and the nurse develop the goals? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to explain an upcoming procedure to an English-speaking Latino client. The nurse determines that the best way to verbally communicate with this client is to:

Correct Answer is A

Explanation

The young client says, “I’m really stressed out about this pregnancy.” When the Practical Nurse (PN) responds, “What about this pregnancy worries you?”, he or she is using the technique of:

Correct Answer is B

Explanation

The Practical Nurse (PN) uses the “risk for” nursing diagnoses as identified from the: Select all that apply

The client does not speak English; therefore, the Practical Nurse (PN) cannot use words to provide comfort during a painful procedure. The PN selects another intervention to provide comfort, which is: * Select one answer

During the planning step of the nursing process, the nurse performs which activity? Select one answer

Which statements describe a desired patient outcome or expected outcome? (Select all that apply)

The Practical Nurse (PN) is caring for a client with dementia and memory loss. Which of the following communication techniques would be most eﬀective? (Select all that apply)

Which statement best defines the nursing process? Select one answer

What should the nurse do with linens that have been soiled by a client with hepatitis?