When a nurse reviews a newly admitted patient's history, which finding(s) will alert the nurse that the patient is at risk for falls? Select all that apply

A.Implementation is the active phase of the nursing process where the nurse carries out the specific interventions previously outlined in the care plan. This stage focuses on the delivery of care, such as medication administration or patient teaching, rather than measuring the success of those actions. It is the "doing" phase that precedes the measurement of outcomes and clinical improvement.

B.Planning involves the formulation of measurable goals and the selection of nursing interventions based on the identified nursing diagnoses. This step occurs early in the process and sets the benchmarks that will eventually be used to judge the effectiveness of the care provided. It does not involve the actual determination of whether those benchmarks were reached in a real-time clinical setting.

C.Assessment is the systematic and continuous collection of data to determine the client's current health status and identify any new or existing problems. While the nurse must assess the patient to see if they improved, the specific act of comparing that improvement against "expected outcomes" is a different step. Assessment provides the raw data, whereas the next phase provides the final judgment.

D.Evaluation is the final step of the nursing process where the nurse compares the patient's actual clinical status against the predefined expected outcomes. This critical thinking step determines if the nursing interventions were effective or if the plan of care requires modification or termination. Meeting all expected outcomes indicates that the goals were achieved and the specific nursing problem is resolved.

A.Approval and accreditation are distinct processes; a program can be approved by the state to operate without being nationally accredited by organizations like the ACEN or CCNE. State approval is mandatory for graduates to be eligible for the NCLEX-RN, while accreditation is a voluntary peer-review process. Accreditation signifies a higher level of educational quality but is not guaranteed by basic state approval.

B.The state legislature writes the laws that comprise the Nurse Practice Act, but it does not directly manage or approve individual nursing programs. The legislature delegates this regulatory authority to a specific administrative agency. The day-to-day oversight, curriculum review, and site visits are conducted by experts in nursing regulation rather than politicians in the legislative branch.

C.The state's board of nursing (BON) is the primary regulatory body responsible for approving nursing education programs within its jurisdiction. The BON ensures that the curriculum, faculty qualifications, and clinical facilities meet the minimum standards necessary to prepare safe and competent entry-level nurses. This governance protects the public by maintaining the integrity and quality of the nursing workforce.

D.The Department of Health and Human Services (HHS) is a federal agency that oversees broad public health initiatives and social services at the national level. While it may influence nursing through funding and policy, it does not have the legal authority to govern or approve specific nursing schools. Regulation of nursing practice and education is a power reserved for the individual states.