The nurse is performing a safety assessment and notes that the patient uses a walker and has difficulty with balance. What should the nurse do first?

Introduction:

Nursing care planning involves creating a structured, individualized roadmap to guide effective clinical interventions. This essential process translates assessment findings into actionable goals and evidence-based strategies, ensuring that the healthcare team provides consistent, safe, and patient-centered care that addresses all identified physiological and psychosocial health needs.

A. Patient allergies are a critical element that must be included in the care plan to ensure patient safety. Identifying and highlighting known sensitivities is essential to prevent adverse medication reactions, adverse events from materials, or dietary complications, which is a foundational requirement for all patient care in any setting.

B. Specific measurable goals are fundamental to the planning phase because they provide a clear, objective benchmark for success. These goals must be concrete and time-bound, allowing the nurse and interdisciplinary team to track patient progress accurately and determine if the current interventions are effective or require modification.

C. Nursing diagnoses provide the clinical focus for the care plan by identifying the patient's actual or potential health problems. These diagnoses serve as the basis for selecting appropriate interventions, ensuring that the care provided is deliberate, evidence-based, and directly targets the patient's specific, unique, and multifaceted health needs.

D. Patient billing information is an administrative and financial record managed by the hospital's billing department. It is not a clinical component of the nursing care plan, which should focus exclusively on health-related status, diagnostic findings, and the therapeutic strategies necessary to improve the patient's overall health outcomes.

E. Planned interventions are the specific, evidence-based nursing actions derived from the nursing diagnoses and goals. These define what the nurse will do to assist the patient, serving as a guide for care delivery and ensuring that the healthcare team remains organized, focused, and proactive in achieving established outcomes.

Introduction:

Professional nursing practice demands adherence to established standards care to prevent foreseeable patient injury. Failure to meet these obligations constitutes a breach of duty, often resulting in legal liability claims.

A. Assault is the intentional act of creating a reasonable apprehension of harmful or offensive contact. In this clinical scenario, the nurse did not threaten the patient with bodily harm. Therefore, it is inappropriate because there was no active attempt to cause fear or threatening behavior toward the patient.

B. Negligence occurs when a professional fails to exercise the degree of care that a reasonably prudent person would exercise in similar circumstances. By failing to follow up on abnormal laboratory results, the nurse breached their duty of care, directly leading to harm, making this a definitive legal failure.

C. Battery is the intentional and unconsented touching of another person. The failure to follow up on lab results is an omission of action rather than an intentional, unauthorized physical contact. Consequently, this classification is incorrect as no physical battery occurred during the care of this patient.

D. Slander refers to the action or crime of making a false spoken statement damaging to a person's reputation. This legal term pertains to defamation of character through oral communication. It is irrelevant here, as the clinical issue involves a failure to perform professional duties, not a communication-based tort.