Answer to Question 1
Correct Answer: 4
Rationale 1: An informal nursing care plan is a strategy for action that exists only in the nurse's mind this does not meet the needs expressed in the item.
Rationale 2: A formal nursing care plan is a written or computerized guide that organizes information about the client's care this does not meet the needs expressed in the item...
Rationale 3: A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs.
Rationale 4: An individualized care plan is tailored to meet the unique needs of a specific clientneeds that are not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine proceduresomething that is unplanned and a rare occurrence and must fit with the needs of the client..
Answer to Question 2
Correct Answer: 3
Rationale 1: The continuation of the client's care plan is not the sole responsibility of the admitting nurse.
Rationale 2: While this is true, there is another option that better answers the item.
Rationale 3: Planning is basically the nurse's responsibility but input from the client and support persons is essential if a plan is to be effective. In this case, therapies from other disciplines (occupational, physical, speech, etc.) would be involved since the client is in a comprehensive rehabilitation center. The client's support people and caregivers are also going to be involved in the plan of care, but not exclusively.
Rationale 4: While it is important for the client and the client's support people and caregivers be involved in the plan of care, there is an option that better answers this item.
A nurse shows empathy to a client.
Developing a two part nursing diagnostic label
Gram Stain Procedure Diagram
Building a Client Base Cont.
Testing client’s ability to identify dull sensation
Client’s view with visual field loss