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Revising the plan as needed occurs in what part of the nursing process?

Evaluation Explanation: Evaluation assesses whether the outcome criteria have been met and revising the plan as necessary. Diagnosis occurs when the data has been analyzed and a professional judgement occurs. Assessment is the collection of data. Planning is determining outcome criteria and developing a plan.

The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.

Making incorrect nursing judgments or diagnoses

Nursing intervention

Nursing interventions are used to monitor health status; prevent, resolve, or control a problem; assist with ADLs; or promote optimum health and independence. Nursing goals are the client's desired outcomes. Nursing evaluation is deciding whether the nursing goals have been reached. Nursing assessment is an overview of the patient's health status and current problems.

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?

evaluation

The result of a nursing assessment is the

formulation of a nursing diagnosis

A client is being admitted to the medical unit after being seen in the emergency department. Which statement by the nurse indicates an understanding of the importance of the appropriate timing of a health assessment?

"I'm going to assess the client now so that I can begin formulating the care plan." Explanation: Each person needs a complete health assessment. Ideally this is done on admission, but extenuating circumstances may prohibit its completion in detail at this time. The sooner the health assessment is completed fully, the better the nurse knows the client, and more holistic care can be provided to ensure health promotion and quality of life. The assessment should not be postponed until after the consult. The family should be informed of the need for the assessment and asked to leave until it is completed, unless their input with the history is needed. While pain may complicate the assessment process, it is not advisable to wait until the client is pain free to complete the assessment.

What is one way nurses use critical thinking in regard to the nursing process?

Critical thinking helps nurses work through the analysis, develop alternatives, and implement the best interventions

Critical thinking

Critical thinking in nursing entails purposeful, outcome-directed (results-oriented) thinking; is driven by client, family, and community needs; is based on the nursing process, evidence-based thinking, and the scientific method; requires specific knowledge, skills, and experience; is guided by professional standards and codes of ethics; and is constantly reevaluating, self-correcting, and striving to improve. Critical thinking does not decide which parts of the nursing process are not needed in caring for a particular client. Nurses are expected to and required to think critically; critical thinking does not allow nurses to make decisions without involving the client in those decisions.

Data being collected during a health assessment causes the nurse to believe there may be additional issues that are possibly affecting the client's health and wellness. What action should the nurse take to best address the suggestion of additional health concerns?

Extend the time originally allotted for the completion of the initial health assessment. Explanation: When the assessment uncovers possible additional health issues, the nurse should allot additional time to sufficiently gather the necessary related data. The additional information is critical to the creation of an effective plan of care. The most effective time to gather the information is during the assessment that is currently being performed. While the family may be able to contribute relevant information, the primary source of information should be the client unless there are extenuating circumstances that make that difficult.

Which of the following is the best example of holistic data collection by a nurse?

Measuring blood pressure, inquiring about a client's nutritional intake, assessing for depression, and asking the client how his condition affects family gatherings Explanation: The purpose of a nursing health assessment is to collect holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment. The nurse collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client. Thus the nurse performs holistic data collection. The mind, body, and spirit are considered to be interdependent factors that affect a person's level of health. The nurse, in particular, focuses on how the client's health status affects his activities of daily living and how the clien's activities of daily living affect his health. For example, a client with asthma may have to avoid extreme temperatures and may not be able to enjoy recreational camping. If this client walks to work in a smoggy environment, it may adversely affect his asthma. The other answers pertain only to the physiologic functioning of the client and not the other aspects.

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessemt on a client who is complaining of shortness of breath. Explanation: The nurse investigating a client problem by performing a focused assessment is exhibiting critical thinking. Transcribing orders, calling a healthcare provider, and answering a call bell are not examples of critical thinking that entail outcome-directed thinking based on the nursing process.

Evaluation stage

The evaluation stage of the nursing process involves assessing whether the outcome criteria have been met and the nursing care plan needs to be revised. The assessment stage involves collecting subjective and objective data. The diagnosis phase involves analyzing subjective and objective data to make a professional nursing judgment. The implementation phase involves carrying out the plan to meet the determined outcome criteria.

During a health assessment the nurse learns that a client lives in an urban area with a high crime rate. Which category of health is affecting this client?

environmental Explanation: The environment influences conditions to promote health. Physical health is the way the body works and adapts. Social well-being identifies relationships that support health. Developmental level focuses on thinking, problem solving, and decision making.

The nurse tells a newly admitted patient that she is going to do a health assessment to help in planning care and educational needs during the patient's hospital stay. Before the physical examination, the nurse should first

take a complete health history Explanation: The health assessment consists of a physical examination and a health history. Information gathered during the health history may help direct the nurse in doing a more complete physical examination on a specific system.