Fundamentals of Nursing Q 5
Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a:
A. Plan is developed for nursing care.
B. Physical assessment begins.
C. List of priorities is determined.
D. Review of the assessment is conducted with other team members.
Correct Answer: A. Plan is developed for nursing care.
The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting.
Option B: Assessment is the first step and involves critical thinking skills and data collection; subjective and objective. Subjective data involves verbal statements from the patient or caregiver. Objective data is measurable, tangible data such as vital signs, intake and output, and height and weight.
Option C: A nursing diagnosis encompasses Maslow’s Hierarchy of Needs and helps to prioritize and plan care based on patient-centered outcomes. In 1943, Abraham Maslow developed a hierarchy based on basic fundamental needs innate for all individuals.
Option D: Data may come from the patient directly or from primary caregivers who may or may not be direct relation family members. Friends can play a role in data collection. Electronic health records may populate data and assist in assessment.