Answer to Question 1
D
Taking appropriate action demonstrates the implementation step of the nursing process.
Assessment involves the gathering of data.
When formulating a nursing diagnosis, the nurse critically examines and analyzes the data and identifies the client's response to a problem. The nurse may then determine priorities.
Planning involves establishing goals and expected outcomes of care.
Answer to Question 2
A, B, D, E
To create a new nutritional plan of care, the nurse must utilize characteristics of a normal nutritional status to gauge effectiveness of the plan. The nurse must be aware of previous patient responses to nursing interventions for altered nutrition to determine the probability of success. The nurse must use established expected outcomes to evaluate the patient's response to care (e.g., patient's weight increases by 0.5 kg/week). The nurse must also be creative when designing innovative nursing interventions to meet the patient's nutritional needs and must demonstrate responsibility by following through with evaluation and counseling to successfully reach goals.
NUrse :0
Nurse-patient interaction; nonverbal communication
The nurse needs to note the source of the patient health history
The nurse is using Standard Precautions to draw blood.
The nurse assesses the patient's ability to use the walker correctly
Nurse measuring the recumbent height of a toddler