NUR 111 Introduction to Health Concepts at Cape Fear Community College

Correct Answer:

Planning

Explanation:

The planning phase of the nursing process involves setting patient-centered goals and expected outcomes. By asking the client what pain goal they have, the nurse collaborates with the patient to establish realistic, individualized objectives. This ensures care is tailored to the patient’s preferences and needs, supporting shared decision-making and effective management of pain.

Why Other Options Are Wrong:

Implementation

This is incorrect because implementation refers to the actual carrying out of interventions designed to achieve established goals. Asking about goals occurs before interventions begin, meaning this step fits into planning, not action.

Evaluation

This option is not correct because evaluation takes place after interventions are performed. In evaluation, the nurse determines whether the goals were met and adjusts the care plan if necessary. Asking about the goal happens before interventions and evaluation.

Assessment

Assessment involves collecting subjective and objective data about the client’s current condition. While pain assessment is part of this phase, asking about the patient’s desired pain goal relates more to goal-setting, which belongs in planning.

Correct Answer:

Implementation.

Explanation:

Implementation is the phase of the nursing process where interventions are carried out. This includes teaching, counseling, and actions aimed at helping the client meet established goals. In this case, instructing the client on how to complete a food diary represents a direct nursing intervention designed to promote adherence to the care plan.

Why Other Options Are Wrong:

Planning.

Planning focuses on setting patient-centered goals and expected outcomes. It outlines what needs to be done but does not involve carrying out the teaching or interventions.

Evaluation.

Evaluation takes place after interventions are implemented. The nurse determines whether the patient met the goals, such as checking if the client maintained the food diary. Explaining how to do it occurs before evaluation.

Assessment.

Assessment is the initial step in the nursing process where data is collected about the patient’s condition. Teaching the client does not involve gathering data but delivering interventions.

Correct Answer:

Confirm the accuracy of the vital signs.

Explanation:

When abnormal vital signs are reported by unlicensed assistive personnel, the nurse’s priority is to first validate their accuracy. Equipment errors, incorrect technique, or misinterpretation can sometimes cause false results. Confirming the accuracy ensures that subsequent actions, including notifying the provider, are based on reliable data. Once confirmed, the nurse must act promptly since the blood pressure is critically high and represents a medical emergency.

Why Other Options Are Wrong:

Report the findings to the charge nurse.

This is incorrect because the nurse must first validate the abnormal results before reporting. Passing along potentially inaccurate data could lead to unnecessary interventions or missed priorities. Accurate confirmation is the essential first step in safe nursing practice.

Continue with the physical assessment as soon as possible.

This option is wrong because abnormal vital signs cannot be ignored while the nurse moves on with another task. A physical assessment should be performed, but not until the abnormal values have been verified. Ignoring validation could place the client at serious risk.

Call the primary health-care provider.

This is incorrect as the immediate next step is to confirm accuracy, not escalate care based on unverified information. Contacting the provider without validating the results may lead to unnecessary alarm. Once confirmed, however, notifying the provider would be appropriate given the dangerously high blood pressure.

Correct Answer:

Pain related to complex factors.

Explanation:

This option is correct because it uses NANDA-approved terminology. “Complex factors” allows for recognition that multiple influences (physical, psychological, or situational) may contribute to the client’s pain, even if diagnostic tests are normal. This provides a professional and measurable basis for care planning.

Why Other Options Are Wrong:

Pain related to unknown etiology.

This wording is not acceptable in nursing diagnoses. Nurses must avoid “unknown” as an etiology because care should be based on observable or modifiable contributing factors.

Pain related to psychosomatic condition.

This is not appropriate terminology and can be stigmatizing. It makes an assumption about the cause of pain rather than focusing on the patient’s current symptoms and contributing factors.

Pain related to client’s report.

The client’s report is evidence of pain (defining characteristic), not a cause. Etiologies should explain contributing factors, not restate the patient’s subjective data.

Correct Answer:

Implementation.

Explanation:

Implementation is the phase of the nursing process where the nurse carries out planned interventions. It includes direct care activities, technical skills, and procedures such as Foley catheter insertion. By applying technical skills, the nurse translates the care plan into action to meet the client’s needs.

Why Other Options Are Wrong:

Noticing.

This is part of Tanner’s Clinical Judgment Model, not the nursing process. It refers to observing cues, not carrying out procedures.

Planning.

Planning involves setting priorities, identifying goals, and determining which interventions will be used. The nurse may decide that a catheter is needed during this phase, but the actual insertion happens during implementation.

Evaluation.

Evaluation takes place after the intervention is completed. The nurse determines whether inserting the Foley catheter helped achieve the desired outcomes, such as relieving urinary retention.

Correct Answer:

Teaching the client about a diabetic diet.

Explanation:

Independent nursing interventions are those that nurses can perform on their own, without a healthcare provider’s order. Patient education, such as teaching about diet, lifestyle changes, or self-care practices, is a classic example. This allows the nurse to promote health and support patient understanding within the scope of nursing practice.

Why Other Options Are Wrong:

Removing sutures from a wound.

This requires a provider’s order and is considered a dependent intervention. It involves a procedure that is not initiated independently by the nurse.

Ordering a chest x-ray.

Nurses cannot independently order diagnostic tests. This is a dependent intervention that requires a healthcare provider’s authorization.

Administering medications for pain.

Medication administration requires a prescription from a licensed provider. Therefore, it is a dependent intervention, not independent.

Correct Answer:

Noticing, Interpreting, Responding, Reflection.

Explanation:

Tanner’s clinical judgment model follows the sequence: noticing, interpreting, responding, and reflecting. Nurses first recognize important cues, then interpret their meaning, respond with appropriate actions, and finally reflect on the outcomes. This structured approach guides safe, effective clinical decision-making and helps improve nursing practice over time.

Why Other Options Are Wrong:

Noticing, Responding, Interpretation, Reflection.

This order is incorrect because interpreting must occur before responding. Nurses need to understand what they are noticing before deciding how to act.

Assessment, Interpretation, Reflection, Responding.

This is wrong because “assessment” is not the term used in Tanner’s model, and responding incorrectly comes after reflection. Reflection always comes last.

Noticing, Diagnosing, Responding, Reflection.

This option is incorrect because Tanner’s model does not include diagnosing. Instead, it emphasizes interpreting the situation, which is broader and not the same as forming a diagnosis.

Correct Answer:

Determining if the medication can be diluted in a beverage.

Explanation:

The nurse demonstrates critical thinking by first considering if the medication can be safely diluted in a beverage. This approach addresses the immediate barrier while maintaining patient compliance and safety. It is a problem-solving step that uses nursing judgment to adapt the medication administration in a way that makes it more acceptable to the client without delaying or compromising treatment.

Why Other Options Are Wrong:

Asking the nurse manager how to approach the situation.

This is not the best first action because the nurse is expected to use critical thinking to address common issues like medication refusal. Seeking managerial input may be necessary later if alternatives fail, but the nurse should first consider safe, independent interventions.

Waiting until the client is more cooperative.

This is unsafe because delaying medication could compromise treatment effectiveness. Essential medications must be given as prescribed, and simply waiting does not resolve the client’s resistance or demonstrate active problem-solving.

Notifying the health-care provider that the client has refused the medication.

While communication with the provider may be required if the nurse cannot resolve the issue, this should not be the first step. Nurses are responsible for exploring safe alternatives before escalating to the provider, making this option premature as the initial action.

Correct Answer:

Base nursing interventions on scientific knowledge.

Consider time management as a priority.

Adapt activities to the individual client.

Respect the dignity of the client.

Encourage the client to participate.

Explanation:

Nursing interventions should be evidence-based, grounded in scientific knowledge to ensure safety and effectiveness. Time management is essential to prioritize and deliver interventions efficiently. Interventions must always be adapted to the unique needs of each client, ensuring individualized care. Respecting dignity is fundamental to ethical nursing practice. Encouraging client participation promotes engagement, autonomy, and adherence, strengthening the nurse–client partnership. These principles together guide safe, holistic, and effective care delivery.

Why Other Options Are Wrong:

Delegation should not be considered when implementing nursing interventions.

This is incorrect because delegation is an essential part of nursing practice. Nurses frequently delegate appropriate tasks to unlicensed assistive personnel while retaining accountability. Ignoring delegation would undermine team-based care and efficiency in client management.

Only include independent nursing interventions in the nursing care plan.

This is wrong because care plans include both independent and collaborative interventions. Nurses often work with physicians, physical therapists, and other professionals to deliver comprehensive care. Limiting plans to only independent interventions would exclude important collaborative measures necessary for patient outcomes.