The basis for designing and selecting nursing interventions to meet client needs is the:

Nurse’s notes

Nursing diagnosis

Doctor’s orders

Care plan

Answer and Explanation

The Correct Answer is A

Choice A reason: This is incorrect because it shows that the nurse is not using a systematic and evidence-based approach to care. The nurse’s notes are a form of documentation, not a source of planning.

Choice B reason: This is correct because it shows that the nurse is using a systematic and evidence-based approach to care. The nursing diagnosis is a clinical judgment that identifies the client’s actual or potential health problems or needs and provides the basis for selecting appropriate interventions.

Choice C reason: This is incorrect because it shows that the nurse is not using a holistic and individualized approach to care. The doctor’s orders are a form of prescription, not a source of planning.

Choice D reason: This is incorrect because it shows that the nurse is confusing the outcome with the process. The care plan is a written document that outlines the goals, interventions, and evaluation of care, not a source of planning.

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Correct Answer is A

Explanation

Choice A reason: “I can see you are worried.” is a therapeutic response by the PN to the family at this time. This response shows empathy, which is the ability to understand and share the feelings of another person. It also acknowledges and validates the family’s emotions, and invites them to express their concerns or fears. Therefore, this choice is correct.

Choice B reason: “Don’t worry, you have nothing to feel guilty about.” is not a therapeutic response by the PN to the family at this time. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also implies that the family should feel guilty, and denies them the opportunity to explore their feelings or thoughts. Therefore, this choice is incorrect.

Choice C reason: “Everything possible is being done.” is not a therapeutic response by the PN to the family at this time. This response shows cliché, which is a communication technique that involves using overused or trite expressions that lack meaning or sincerity. It also avoids addressing the family’s emotions or needs, and may sound vague or insincere. Therefore, this choice is incorrect.

Choice D reason: “Let me check if you can see your loved one.” is not a therapeutic response by the PN to the family at this time. This response shows changing the subject, which is a communication technique that involves shifting the focus away from the other person’s feelings or situation. It also ignores or postpones the family’s emotional needs, and may make them feel unimportant or dismissed. Therefore, this choice is incorrect.

A. Provide the client with a towel and tell the client the nurse will assist her when he/she is finished administering the tube feeding B. Stop administering the tube feeding and assist the client who spilled coﬀee with changing her wet clothing and C. assess for burns D. Request a replacement tray and assist the client with changing her wet clothing

Correct Answer is ["B"]

Explanation

Choice A reason: This is incorrect because it shows a lack of empathy and priority for the client who spilled coﬀee. The nurse should not delay providing care for a client who may have suﬀered a burn.

Choice B reason: This is correct because it shows that the nurse prioritizes the safety and comfort of the client who spilled coﬀee. The nurse should stop the tube feeding and assess for burns, which can be a serious complication.

Choice C reason: This is incorrect because it does not address the potential burn injury of the client who spilled coﬀee. The nurse should not focus on replacing the tray before assessing for burns.

Choice D reason: This is correct because it shows that the nurse delegates appropriately and ensures that both clients receive timely care. The nurse should stop the tube feeding and request another nurse to assist the client who spilled coﬀee.

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The basis for designing and selecting nursing interventions to meet client needs is the:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Family members awaiting the outcome of a suicide atempt are tearful. Which response by the Practical Nurse (PN) is therapeutic to the family at this time? * Select one answer

Correct Answer is A

Explanation

A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coﬀee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)

Correct Answer is ["B"]

Explanation

A Practical Nurse (PN) is observing a nursing assistant talking to a client who is hearing impaired. The PN should not intervene if which of the following were performed by the nursing assistant during communication with the client: (Select all that apply)

A patient roughly asks the nurse to bring him some ice cream. An assertive response by the nurse is:

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

When a female client preparing for surgery suddenly bursts into tears, the nurse should take which of the following actions? · Select one answer

Which of the following are approved nursing diagnoses? (Select all that apply)

The nurse preceptor is instructing the new nurse on appropriate communication techniques. The new nurse indicates a need for further teaching on using assertive communication, if she does which of the following when communicating with patients? Select one answer

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