The client's plan of care is created by the nurse using which guideline for nursing practice?

Nursing process

Nursing’s Social Policy Statement

Nurse Practice Act

ANA Standards of Nursing Practice

Answer and Explanation

The Correct Answer is A

Choice A reason: The nursing process (assessment, diagnosis, planning, implementation, evaluation) guides the creation of a client’s care plan, providing a systematic, evidence-based framework. It ensures individualized, goal-oriented care, addressing client needs comprehensively, and is the cornerstone of clinical decision-making, per nursing practice standards.

Choice B reason: Nursing’s Social Policy Statement defines the profession’s role and societal obligations, not a practical guide for care planning. It provides a philosophical framework, not actionable steps like the nursing process, making it irrelevant for creating specific client care plans, per professional guidelines.

Choice C reason: The Nurse Practice Act regulates licensure and scope of practice, not care plan development. It ensures legal compliance but does not provide a clinical framework like the nursing process, which directly structures patient care, making this incorrect for care planning, per regulatory standards.

Choice D reason: ANA Standards of Nursing Practice outline professional expectations but are not a step-by-step guide like the nursing process. They support quality care but lack the specific, systematic approach needed for creating individualized care plans, per nursing practice and clinical guideline frameworks.

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Correct Answer is D

Explanation

Choice A reason: Sodium 138 mEq/L (normal 135-145 mEq/L) is within normal range. Sodium regulates osmotic balance and nerve conduction. Normal levels do not explain tremors, which are often linked to neurological or electrolyte imbalances, like low magnesium. In the context of acute tremors, sodium is not a concern compared to magnesium deficiency.

Choice B reason: Chloride 100 mEq/L (normal 98-106 mEq/L) is normal and does not contribute to tremors. Chloride supports acid-base balance and neuronal inhibition via GABA receptors. Tremors are more likely caused by low magnesium, which affects neuromuscular excitability. Normal chloride levels do not warrant concern in this acute neurological presentation.

Choice C reason: Potassium 4.1 mEq/L (normal 3.5-5.0 mEq/L) is normal and unlikely to cause tremors. Potassium regulates membrane potential and muscle contraction. Tremors are more associated with magnesium deficiency, which increases neuronal excitability. Normal potassium does not explain the neurological symptoms, making it a lower priority than magnesium in this scenario.

Choice D reason: Magnesium 1.0 mEq/L (normal 1.7-2.2 mEq/L) indicates hypomagnesemia, which causes tremors by increasing neuromuscular excitability. Magnesium stabilizes neuronal membranes and regulates calcium channels. Low levels disrupt nerve signaling, leading to tremors and potential seizures. This critical imbalance requires urgent correction, making it the most concerning lab value in this scenario.

A. The Quality and Safety Education for Nurses B. The American Nurses Association Standards of Professional Performance C. The American Nurses Association Code of Ethics D. The American Nurses Association Standards of Practice

Correct Answer is C

Explanation

Choice A reason: The Quality and Safety Education for Nurses (QSEN) focuses on competencies like patient safety and quality improvement, not moral standards. It guides nursing education to enhance clinical skills and patient outcomes, addressing evidence-based practice and teamwork. Moral standards, involving ethical decision-making and professional conduct, are governed by the ANA Code of Ethics, not QSEN.

Choice B reason: The American Nurses Association Standards of Professional Performance outline behaviors like leadership and collaboration but focus on professional competence, not moral standards. These standards guide performance expectations, such as resource utilization and communication, rather than ethical principles like beneficence or autonomy, which are central to the ANA Code of Ethics for moral guidance.

Choice C reason: The American Nurses Association Code of Ethics provides moral standards for nursing, emphasizing principles like beneficence, nonmaleficence, autonomy, and justice. It guides ethical decision-making in patient care, addressing dilemmas like informed consent and confidentiality. This code ensures nurses uphold moral integrity in professional behavior, making it the correct guide for ethical standards.

Choice D reason: The American Nurses Association Standards of Practice define the nursing process (assessment, diagnosis, planning, etc.) but focus on clinical practice standards, not moral guidelines. These standards ensure competent care delivery but do not address ethical principles like patient autonomy or ethical dilemmas, which are covered by the ANA Code of Ethics.

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The client's plan of care is created by the nurse using which guideline for nursing practice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient began to have hand and face tremors after being brought into the Emergency Department. Labs were immediately drawn on this patient. Which labs would most likely concern the nurse at this time?

Correct Answer is D

Explanation

A nurse is using a guide to provide moral standards for professional behavior in nursing. Which guide is the nurse using?

Correct Answer is C

Explanation

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The client's plan of care is created by the nurse using which guideline for nursing practice?

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