What is the primary purpose of the outcome identification and planning step of the nursing process?
To design a plan of care for and with the client.
To collect and analyze data to establish a database.
To interpret and analyze data so as to identify health problems.
To write appropriate client-centered nursing diagnoses.
The Correct Answer is A
Choice A rationale
The outcome identification and planning step of the nursing process is specifically designed to develop a personalized plan of care. This involve setting realistic, measurable, and client-centered goals based on the identified nursing diagnoses. By collaborating with the client, the nurse ensures that the interventions are acceptable to the individual and tailored to their specific needs. This stage serves as a roadmap for the implementation phase, providing clear direction for all members of the healthcare team.
Choice B rationale
Collecting and analyzing data to establish a database is the primary purpose of the Assessment phase, which is the first step of the nursing process. During assessment, the nurse gathers subjective and objective information through interviews, physical examinations, and review of medical records. This data collection is essential for identifying the client's health status, but it occurs before the planning phase, as the plan cannot be formulated without a comprehensive understanding of the patient's baseline.
Choice C rationale
Interpreting and analyzing data to identify health problems and risks is the hallmark of the Nursing Diagnosis phase. This is the second step of the nursing process, where the nurse uses clinical reasoning to determine the client's response to actual or potential health conditions. While this phase is critical for informing the plan of care, the primary goal of the planning phase itself is the subsequent development of goals and strategies to address those diagnosed problems.
Choice D rationale
Writing client-centered nursing diagnoses is the output of the Nursing Diagnosis phase, not the Planning phase. A nursing diagnosis is a clinical judgment about the individual, family, or community. Once these diagnoses are established, the nurse then moves into the Outcome Identification and Planning phase to determine how to resolve or manage those specific issues. Planning relies on the accuracy of the diagnoses to ensure that the goals set are relevant to the client's actual health needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Gross motor development follows a cephalocaudal and proximodistal pattern. Rolling from side to side is one of the earliest motor milestones, typically occurring around 3 to 4 months of age as the infant gains trunk control and neck strength. This skill precedes more complex movements like sitting or standing because it requires less postural stability and muscular coordination. It marks the transition from reflexive movements to more purposeful, voluntary physical activity in the infant's development.
Choice B rationale
Standing while holding on to furniture, often called cruising, is a late infancy milestone that usually occurs between 8 and 10 months of age. This skill requires significant leg strength, balance, and the ability to bear weight through the lower extremities. Because it involves vertical orientation and complex coordination of the large muscle groups, it develops much later than horizontal movements like rolling. It is a precursor to independent walking but is not the first skill developed.
Choice C rationale
Transferring an object from one hand to the other is a fine motor skill that typically emerges around 6 to 8 months of age. This requires the maturation of the nervous system to allow for cross-midline coordination and the voluntary release of an object. While it is an important developmental marker, gross motor skills like rolling side to side occur earlier in the first year as the infant begins to explore their physical environment through movement.
Choice D rationale
Sitting upright unsupported is a milestone that usually occurs around 6 to 8 months. To achieve this, the infant must have developed sufficient core strength and the ability to maintain balance without using their arms for support. While sitting is a fundamental motor skill, the physical requirements for rolling are met much earlier in the developmental timeline. Therefore, rolling side to side is the correct answer as it is the first skill listed to appear.
Correct Answer is D
Explanation
Choice A rationale
Controlled hypertension is a chronic medical condition, but it is not inherently characterized by the presence of chronic pain. Hypertension is often referred to as a silent killer because it usually presents without symptomatic pain unless a crisis occurs. While the management is long-term, the pathology does not involve the continuous activation of pain receptors or the inflammatory processes that lead to the persistent, debilitating discomfort seen in chronic pain.
Choice B rationale
Pneumonia is an acute inflammatory condition of the lung parenchyma, usually caused by infection. The pain associated with pneumonia, such as pleuritic chest pain, is considered acute because it has a sudden onset and is directly related to the active infection and inflammation. Once the underlying infection is treated with antibiotics or antivirals and the inflammation subsides, the pain typically resolves completely within a relatively short timeframe.
Choice C rationale
The flu, or influenza, is an acute viral respiratory infection that causes systemic symptoms including fever, malaise, and myalgia. The muscle aches and headaches associated with the flu are acute in nature, lasting only as long as the viral replication and the body's primary immune response are active. This discomfort does not persist beyond the healing phase and therefore does not meet the clinical criteria for chronic pain.
Choice D rationale
Rheumatoid arthritis is a chronic autoimmune and inflammatory disease where the immune system attacks the synovium of the joints. This results in persistent, long-term pain and joint damage that lasts well beyond the typical healing time of 3 to 6 months. Because the condition is progressive and incurable, the patient experiences chronic pain that requires ongoing management to mitigate systemic inflammation and maintain functional mobility over a lifetime.
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