Author Question: The nurse is caring for a confused client. The nurse informs the client of the date, day of the ... (Read 141 times)

KWilfred · **on:** Jun 25, 2018

The nurse is caring for a confused client. The nurse informs the client of the date, day of the week, time, and location each time the room is entered.

Which step of the nursing process is the nurse using to orient this client?
1. Implementation.
2. Evaluation.
3. Planning.
4. Assessment.

Question 2

The nurse is reviewing the care plan for a client with schizophrenia.

Upon assessment the client admits to hearing voices that say, Kill yourself. The nurse documents the client is at risk for injury and includes the following statement in the plan of care, Client will not harm self during hospitalization. Which step of the nursing process is the nurse using?
1. Goal setting.
2. Implementation.
3. Diagnosis.
4. Evaluation.

macagn · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1

Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. A confused client needs reorientation as part of the nursing care provided. Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Assessment is the phase of obtaining subjective and objective data about the client.

Answer to Question 2

Correct Answer: 1
Goal setting occurs after a diagnosis has been formulated. The statement written is a goal for the client during hospitalization. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. The diagnosis is formulated after data have been collected, and goal setting occurs after a diagnosis has been formulated. Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. The nurse's recorded observations indicate the goals of the nursing care plan have been achieved.