The nurse has completed the initial assessment of a client and ...

[tnt_battle]

The nurse has completed the initial assessment of a client and has analyzed and clustered the data. What should the nurse complete next in the diagnostic process?
 
  1. Formulate a diagnosis.
  2. Verify the data.
  3. Research collaborative and nursing-related interventions.
  4. Identify the client's problem, health risks, and strengths.

Question 2

After formulating several diagnoses, the nurse does not understand the reason for some of the discrepancies in the client's lab values and diagnostic tests, when comparing to norms and standards. Which action should the nurse take?
 
  1. Verify the information with the client.
  2. Compare all findings to the national norms and standards.
  3. Consult other professionals and colleagues.
  4. Improve critical thinking skills so answers come more easily.

[aloop]

Answer to Question 1

Correct Answer: 4
Rationale 1: There are steps in the process that precede the formulation of diagnostic statements.
Rationale 2: Verifying the data should be done at the end of the assessment/interview phase.
Rationale 3: Researching collaborative and nursing-related interventions comes after setting goals or outcomes and is not part of the diagnostic process, but rather part of the implementation phase.
Rationale 4: The step that follows data analysis is identification of the client's health problems, health risks, and strengths.

Answer to Question 2

Correct Answer: 3
Rationale 1: Verifying the information with the client would be inappropriate because the information does not come from subjective data, but rather from testing and lab values.
Rationale 2: The nurse already has compared the findings to the norms and standards.
Rationale 3: Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis. Professional literature, nursing colleagues, and other professionals are all appropriate resources.
Rationale 4: Critical-thinking skills help the nurse be aware of and avoid errors. This comes with experience and is a learned and practiced process.