Choice A reason:.

Establishing a baseline for planning care and evaluating outcomes is the main purpose of the assessment phase of the nursing process. The assessment phase involves collecting data about the client's health status and needs, which will help the nurse to identify any problems or potential problems that may need to be addressed. The assessment data will also serve as a reference point for comparing the client's progress and outcomes throughout the nursing process.

Choice B reason:.

Identifying the client's response to health concerns or illness is part of the diagnosis phase of the nursing process. The diagnosis phase involves analyzing the data collected during the assessment phase and identifying the client's problems and strengths. The nurse then formulates a nursing diagnosis, which is a statement of the client's actual or potential health problem that can be addressed by nursing interventions.

Choice C reason:.

Providing goal-directed, client-centered care is part of the planning and implementation phases of the nursing process. The planning phase involves setting goals and outcomes for the client and selecting appropriate interventions to achieve them. The goals and outcomes should be specific, measurable, attainable, realistic, and timely (SMART), and they should reflect the client's preferences and values. The implementation phase involves carrying out the interventions and documenting the actions and responses. The interventions should be evidence-based, safe, and effective, and they should involve the client as much as possible.

Choice D reason:.

Comparing the client's data with expected standards or reference ranges is part of the evaluation phase of the nursing process. The evaluation phase involves evaluating the effectiveness of the interventions and modifying the plan as needed. The nurse compares the client's actual outcomes with the expected outcomes and determines whether the goals have been met, partially met, or not met. The nurse also identifies any factors that may have influenced the outcomes, such as client compliance, environmental factors, or unexpected events.

Choice A reason:

Asking the client when they first noticed the symptoms is a relevant and appropriate question for a problem-focused assessment. It helps the nurse to determine the onset, duration, and frequency of the nausea and vomiting, which can provide clues to the possible causes and severity of the problem.

Choice B reason:

Asking the client about allergies or food intolerances is not directly related to the problem of nausea and vomiting. It might be useful to ask this question later in the assessment, but it is not the priority at this point. This question is more suitable for a comprehensive or initial assessment.

Choice C reason:

Asking the client to rate their pain on a scale of 0 to 10 is not relevant to the problem of nausea and vomiting. Pain is a different symptom that might or might not be associated with nausea and vomiting. This question is more suitable for a pain assessment.

Choice D reason:

Asking the client about their health goals is not related to the problem of nausea and vomiting. This question is more suitable for a wellness assessment or a health promotion intervention.

Choice A reason:

Asking about family history of heart disease or stroke is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the client's risk factors, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

Choice B reason:

Asking how long the client has been feeling this way is a priority question for a client who is experiencing chest pain and shortness of breath. This question helps to determine the onset and duration of the symptoms, which are important factors for diagnosing and treating the client. For example, if the client has been feeling this way for more than 20 minutes, it may indicate a myocardial infarction (heart attack), which requires urgent intervention. Therefore, this is the best choice.

Choice C reason:

Asking about medications or supplements is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the client's medical history and possible drug interactions, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

Choice D reason:

Asking what the client was doing when the pain started is not a priority question for a client who is experiencing chest pain and shortness of breath. This question may be relevant for assessing the possible triggers or precipitating factors of the symptoms, but it does not address the immediate problem or help to determine the cause of the symptoms. Therefore, this is not the best choice.

Choice A reason:

The client states that he has trouble sleeping at night. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice B reason:

The client has a blood pressure of 150/90 mm Hg. This is objective data because it is information that the nurse observes when conducting a physical assessment. Objective data is measurable and observable.

Choice C reason:

The client reports feeling anxious about his diagnosis. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice D reason:

The client prefers not to discuss his personal issues. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice A reason:

It involves determining the effectiveness of nursing interventions. This is the correct definition of the evaluation phase of the nursing process, which is the final step where the nurse compares the actual outcomes with the expected outcomes and modifies the plan of care if needed.

Choice B reason:

It involves establishing priorities and measurable outcomes. This is not the correct definition of the evaluation phase, but rather the planning phase of the nursing process, which is the third step where the nurse identifies client goals and interventions based on the nursing diagnosis.

Choice C reason:

It involves identifying gaps between actual and expected findings. This is not the correct definition of the evaluation phase, but rather a component of it. Identifying gaps between actual and expected findings is one way to determine the effectiveness of nursing interventions, but it is not the only way. The evaluation phase also involves documenting and communicating the results of the evaluation.

Choice D reason:

It involves selecting appropriate evidence-based interventions. This is not the correct definition of the evaluation phase, but rather another component of the planning phase of the nursing process, which is the third step where the nurse identifies client goals and interventions based on the nursing diagnosis.

Choice A reason:

Consulting with other members of the health care team is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While collaboration is important, the nurse should first involve the client in decision making to ensure that the plan of care is individualized, realistic and acceptable to the client.

Choice B reason:

Involve the client in decision making is the correct answer. This is the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. Involving the client in decision making promotes self-management, adherence and empowerment. The client is the best source of information about their preferences, goals and needs.

Choice C reason:

Reviewing current literature on diabetes management is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While evidence-based practice is essential, the nurse should first involve the client in decision making to ensure that the plan of care is based on the client's situation and values.

Choice D reason:

Identifying realistic and measurable outcomes is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While outcome identification is a key step in the nursing process, the nurse should first involve the client in decision making to ensure that the outcomes are relevant and achievable for the client.

Choice A reason:

Administering nitroglycerin sublingually as ordered is the next priority action for the nurse because nitroglycerin is a medication that relaxes the heart arteries and improves blood flow to the heart muscle, which can relieve chest pain and shortness of breath caused by coronary artery disease. Nitroglycerin can also lower blood pressure, which can help reduce the workload of the heart and prevent further damage to the heart muscle. Nitroglycerin is a fast-acting medication that should be given as soon as possible after chest pain occurs or is suspected.

Choice B reason:

Obtaining a complete health history from the patient is not the next priority action for the nurse because it is not an urgent intervention that can address the patient's immediate needs. A complete health history can provide valuable information about the patient's risk factors, past medical history, medications, allergies, and family history, but it can also take a long time to obtain and may not be feasible if the patient is in pain or distress. A complete health history can be obtained later after the patient's condition is stabilized and more urgent interventions are done.

Choice C reason:

Educating the patient about lifestyle modifications is not the next priority action for the nurse because it is not an acute intervention that can relieve the patient's symptoms or prevent further complications. Lifestyle modifications such as quitting smoking, eating a healthy diet, exercising regularly, managing stress, and controlling blood pressure and cholesterol levels are important for preventing or managing coronary artery disease in the long term, but they do not have an immediate effect on the patient's condition. Educating the patient about lifestyle modifications can be done later after the patient's condition is improved and the patient is ready to learn.

Choice D reason:

Preparing the patient for cardiac catheterization is not the next priority action for the nurse because it is not a definitive intervention that can confirm or rule out coronary artery disease or other causes of chest pain and shortness of breath. Cardiac catheterization is a diagnostic procedure that involves inserting a thin tube into an artery in the groin or arm and advancing it to the heart to inject contrast dye and take X-ray images of the heart and blood vessels. Cardiac catheterization can help identify blockages or narrowing in the coronary arteries that may cause chest pain and shortness of breath, but it also carries some risks such as bleeding, infection, allergic reaction, kidney damage, or heart attack. Cardiac catheterization may be ordered by the physician after other tests such as ECG, blood tests, or.

Choice A reason:

Assessing the patient's vital signs and oxygen saturation is the first step in evaluating the patient's response to pain medication. This is because vital signs and oxygen saturation can indicate the severity of pain, the effectiveness of the medication, and the presence of any adverse effects such as respiratory depression or hypotension. Assessing vital signs and oxygen saturation is also consistent with the nursing process of assessment, which guides the nurse's subsequent actions.

Choice B reason:

Notifying the physician and requesting a different medication is not the first action that the nurse should take. The nurse should first assess the patient's condition and determine the cause of inadequate pain relief. The physician may not be available or may not agree to change the medication without further information. Changing the medication may also not be necessary or appropriate, depending on the patient's pain level, type of pain, allergies, contraindications, and preferences.

Choice C reason:

Reassessing the patient's pain level in another 15 minutes is not the first action that the nurse should take. The patient is reporting a high level of pain (8 out of 10) despite receiving morphine 10 mg intravenously 30 minutes ago. This indicates that the patient is experiencing breakthrough pain, which is a sudden increase in pain intensity that occurs despite adequate analgesia. Breakthrough pain requires immediate attention and intervention, not delayed reassessment.

Choice D reason:

Providing nonpharmacological interventions such as massage or distraction is not the first action that the nurse should take. Nonpharmacological interventions are complementary methods that can enhance the effect of pharmacological interventions, but they are not sufficient to treat severe acute pain by themselves. The nurse should first assess the patient's condition and administer additional analgesia if indicated and prescribed before implementing nonpharmacological interventions.

Choice A:

Compare the data with normal standards and ranges. This is a valid action for the nurse to take, because it helps to identify any abnormal findings or deviations from the expected values. For example, the nurse can compare the client's blood pressure, pulse, and temperature with the normal ranges for adults.

Choice B:

Use open-ended questions to clarify the data. This is also a valid action for the nurse to take, because it allows the client to provide more information and elaborate on their responses. Open-ended questions are those that cannot be answered with a simple yes or no, such as "How do you feel about your condition?.”. or "What are your main concerns?.".

Choice C:

Repeat the assessment using a different method or source. This is another valid action for the nurse to take, because it helps to confirm the accuracy and reliability of the data. For example, the nurse can use a different device to measure the blood pressure, ask another health care professional to verify the findings, or check the client's medical records for previous data.

Choice D:

All of the above. This is the correct answer, because all of the actions listed above are appropriate ways for the nurse to validate the data collected from an assessment of a client who has hypertension. Validation is an important step in the assessment process, because it ensures that the data are complete, accurate, and consistent.

Choice A reason:

This statement is not objective data because it is based on what the client states, not what the nurse observes or measures. This is an example of subjective data, which is information that depends on personal feelings.

Choice B reason:

This statement is objective data because it is based on what the nurse observes or measures using a thermometer and a pulse oximeter. This is an example of objective data, which is information that is factual and can be verified.

Choice C reason:

This statement is not objective data because it is based on the nurse's interpretation of the client's appearance and behavior, not on direct observation or measurement. This is an example of subjective data, which is information that represents the patient's perceptions, feelings, or concerns.

Choice D reason:

This statement is not objective data because it is based on what the client reports, not what the nurse observes or measures. This is an example of subjective data, which is information that the patient tells the nurse that cannot be measured or observed.

Choice A reason:

Identifying the client's health problems is not the first step in formulating a diagnostic statement. The nurse needs to gather and analyze the assessment data before identifying the health problems.

Choice B reason:

Clustering the assessment data is the first step in formulating a diagnostic statement. The nurse groups related data together to identify patterns and relationships that indicate a human response to health conditions or life processes.

Choice C reason:

Validating the data with the client is not the first step in formulating a diagnostic statement. The nurse needs to cluster the data first and then validate it with the client to ensure accuracy and completeness.

Choice D reason:

Prioritizing the health problems is not the first step in formulating a diagnostic statement. The nurse needs to cluster the data first and then identify the health problems before prioritizing them.

Choice A reason:

The PES format (problem, etiology, signs and symptoms) is the most comprehensive and accurate way to write a nursing diagnostic statement. It identifies the nursing problem, the cause or contributing factors, and the evidence or manifestations of the problem. For example, a possible PES statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern related to chronic airway obstruction as evidenced by dyspnea, tachypnea, and use of accessory muscles.

Choice B reason:

The PE format (problem, etiology) is a two-part diagnostic statement that omits the signs and symptoms of the problem. It is less specific and does not provide enough information to guide the nursing interventions and outcomes. For example, a possible PE statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern related to chronic airway obstruction. This statement does not indicate how the problem is manifested or measured.

Choice C reason:

The PS format (problem, signs and symptoms) is a two-part diagnostic statement that omits the etiology or cause of the problem. It is less precise and does not identify the factors that contribute to or influence the problem. For example, a possible PS statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern as evidenced by dyspnea, tachypnea, and use of accessory muscles. This statement does not indicate why the problem exists or what can be done to address it.

Choice D reason:

The ES format (etiology, signs and symptoms) is a two-part diagnostic statement that omits the problem or nursing diagnosis. It is incomplete and does not state what the actual or potential health issue is. For example, a possible ES statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Chronic airway obstruction as evidenced by dyspnea, tachypnea, and use of accessory muscles. This statement does not indicate what the nursing problem is or what the desired outcome is.

Choice A reason:

The client will ambulate 50 feet with a walker by day 3. This is an example of a goal rather than an outcome because it is a specific action that the client intends to achieve within a certain time frame. It is also a process goal because it is a step or sub-goal towards a more significant and overarching goal, such as improving mobility or preventing complications. Process goals are more controllable and measurable than outcome goals.

Choice B reason:

The client will maintain fluid balance as evidenced by stable weight and urine output. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

Choice C reason:

The client will have improved gas exchange as indicated by oxygen saturation above 92%. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

Choice D reason:

The client will have normal bowel function. This is an example of an outcome rather than a goal because it is the overarching result that the client intends to achieve. It is also an outcome goal because it enables the client to assess their present and intended performance results while developing an outline that guides the steps to realize it. Outcome goals are more general and less controllable than process goals.

Choice A reason:

Independent nursing interventions are actions that nurses can perform by themselves, without any management from a doctor or another discipline. For example, checking vital signs, repositioning a patient, or providing patient education are independent nursing interventions. These interventions do not require a health care provider's order.

Choice B reason:

Dependent nursing interventions are actions that nurses perform under the direction of a physician or as part of a care plan. For example, administering medications, performing diagnostic tests, or inserting an intravenous line are dependent nursing interventions. These interventions require a health care provider's order.

Choice C reason:

Collaborative nursing interventions are actions that nurses perform in coordination with other health care professionals, such as physicians, pharmacists, dietitians, or physical therapists. For example, developing a discharge plan, implementing a wound care protocol, or providing nutritional counseling are collaborative nursing interventions. These interventions may or may not require a health care provider's order, depending on the situation and the scope of practice of the nurse.

Choice D reason:

Evaluative nursing interventions are not a type of intervention, but rather a step in the nursing process. Evaluative nursing interventions are actions that nurses take to assess the outcomes of their care and the effectiveness of their interventions. For example, measuring pain levels, monitoring wound healing, or evaluating patient satisfaction are evaluative nursing interventions. These interventions do not require a health care provider's order.

Choice A reason:

The nurse uses a mechanical lift to transfer the client from bed to chair. This is the correct answer because it demonstrates the use of appropriate resources and equipment to prevent injury to the client and the nurse, and to facilitate safe mobility for the client who has impaired mobility due to a stroke. A mechanical lift is a device that helps lift and move a person who cannot move on their own or with minimal assistance.

Choice B reason:

The nurse performs passive range of motion exercises for the affected limbs. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps maintain joint mobility, prevent contractures, and improve circulation for the client who has impaired mobility due to a stroke. Passive range of motion exercises are movements that are done by someone else for a person who cannot move their own limbs.

Choice C reason:.

The nurse encourages the client to participate in physical therapy sessions. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps promote recovery, prevent complications, and improve function for the client who has impaired mobility due to a stroke. Physical therapy is a type of rehabilitation that involves exercises and activities that help improve strength, balance, coordination, and mobility.

Choice D reason:

The nurse applies antiembolic stockings and sequential compression devices to the lower extremities. This is not the correct answer because it does not demonstrate the use of appropriate resources and equipment, but rather a nursing intervention that helps prevent deep vein thrombosis (DVT), a potential complication of stroke that occurs when a blood clot forms in a vein deep in the body. Antiembolic stockings are tight-fitting elastic socks that apply pressure to the legs and feet to improve blood flow and prevent clotting. Sequential compression devices are inflatable sleeves that wrap around the legs and inflate and deflate periodically to squeeze the veins and improve blood flow.

Choice A reason:

The nurse reports any changes in the client's vital signs, weight, or fluid status to the primary provider. This action demonstrates the skill of collaborating and communicating with other health care providers because it involves sharing relevant and timely information about the client's condition and needs with the primary provider, who can then make appropriate decisions or adjustments to the plan of care. Reporting changes in vital signs, weight, or fluid status is especially important for a client who has chronic heart failure, as these indicators can reflect worsening or improving cardiac function. Reporting changes also follows the ISBARR format of communication, which is a standardized method of exchanging patient information between health care team members.

Choice B reason:

The nurse administers prescribed medications, such as diuretics, beta blockers, and ACE inhibitors. This action does not demonstrate the skill of collaborating and communicating with other health care providers because it is a routine nursing task that does not involve direct interaction or exchange of information with other health care team members. Administering medications is part of the nurse's scope of practice and responsibility, and does not require collaboration or communication with other providers, unless there are questions, concerns, or issues regarding the medication orders.

Choice C reason:

The nurse educates the client about lifestyle modifications, such as sodium restriction, exercise, and smoking cessation. This action does not demonstrate the skill of collaborating and communicating with other health care providers because it is a nursing intervention that focuses on the client's education and self-management, not on the interaction or exchange of information with other health care team members. Educating the client about lifestyle modifications is part of the nurse's role in promoting health and preventing complications, and does not require collaboration or communication with other providers, unless there are discrepancies or inconsistencies in the education materials or messages.

Choice D reason:.

The nurse assesses the client's cardiac function, such as heart sounds, rhythm, and peripheral pulses. This action does not demonstrate the skill of collaborating and communicating with other health care providers because it is a nursing assessment that does not involve direct interaction or exchange of information with other health care team members. Assessing the client's cardiac function is part of the nurse's role in monitoring and evaluating the client's response to treatment, and does not require collaboration or communication with other providers, unless there are abnormal findings that need to be reported or documented.

Choice A reason:

Reporting the errors or omissions to the quality improvement committee is not the best action to take because it does not address the immediate needs of the client or correct the plan of care. Quality improvement committees are responsible for monitoring and evaluating the quality of care and services provided by the health care organization, but they are not directly involved in the care of individual clients. Reporting the errors or omissions to the committee may be appropriate after discussing and revising the plan of care with the health care team, but it is not the first or most important action to take.

Choice B reason:

Discussing the errors or omissions with the health care team and revising the plan of care accordingly is the best action to take because it ensures that the client receives safe and effective care that meets their needs and preferences. Errors or omissions in a plan of care are failures to do the right thing that may cause harm or poor outcomes for the client Examples of errors or omissions in a plan of care include failing to order necessary tests, procedures, medications, or consultations; failing to document or communicate important information; failing to monitor or evaluate the client's condition or response to treatment; or failing to follow evidence-based guidelines or standards of care Discussing the errors or omissions with the health care team allows for identifying and correcting the causes of the errors or omissions, such as lack of knowledge, skills, resources, communication, coordination, or supervision. Revising the plan of care accordingly allows for updating and modifying the goals, interventions, and outcomes based on the client's current status and needs.

Choice C reason:

Ignoring the errors or omissions as they are not significant enough to affect outcomes is not a good action to take because it violates the ethical principles of beneficence and nonmaleficence, which require nurses to do good and avoid harm for their clients Ignoring the errors or omissions may also lead to legal consequences, such as negligence or malpractice claims, if the client suffers harm or injury as a result of the errors or omissions Furthermore, ignoring the errors or omissions does not contribute to improving the quality and safety of care or preventing future errors or omissions from occurring.

Choice D reason:

Documenting the errors or omissions in an incident report and filing it in the client's chart is not a good action to take because it does not correct the errors or omissions or revise the plan of care. Incident reports are tools for documenting and analyzing adverse events or near misses that occur in health care settings, such as medication errors, falls, infections, or equipment failures Incident reports are not part of the client's medical record and should not be filed in their chart. They are confidential documents that are used for quality improvement purposes, such as identifying system failures, implementing corrective actions,.

Choice A reason:

The size and depth of the ulcer are important indicators of the severity and healing progress of the wound. The nurse should measure the length, width, and depth of the ulcer using a ruler or a probe and document the findings. The nurse should also note the presence of any undermining or tunneling in the wound bed.

Choice B reason:

The presence of drainage or odor can signal infection or necrosis in the wound. The nurse should assess the amount, color, consistency, and odor of the drainage and document the findings. The nurse should also culture the wound if indicated and initiate appropriate wound care interventions.

Choice C reason:

The type and amount of pain medication administered are not directly related to the assessment of the pressure ulcer. Pain is a subjective experience that varies among individuals and situations. The nurse should assess the client's pain level using a valid pain scale and administer analgesics as prescribed, but this is not part of the ongoing assessment of the wound itself.

Choice D reason:

The client's nutritional status and intake are vital factors that affect wound healing. The nurse should assess the client's weight, body mass index, serum albumin, prealbumin, and transferrin levels, and dietary intake of protein, calories, vitamins, minerals, and fluids. The nurse should also provide nutritional supplements or consult a dietitian as needed to optimize the client's nutritional status.

Choice E reason:

The client's level of mobility and activity are also important factors that influence wound healing. The nurse should assess the client's ability to move, reposition, and ambulate independently or with assistance. The nurse should also implement measures to reduce pressure, shear, and friction on the wound site, such as using pressure-relieving devices, turning and repositioning the client frequently, and providing skin care.

Choice A reason:

Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.

Choice B reason:

Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.

Choice C reason:

Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.

Choice D reason:

Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.

Choice E reason:

Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.

Choice A:

Positioning the patient in high Fowler's position. This is a correct intervention because it allows for optimal chest expansion and lung ventilation, reducing dyspnea and work of breathing.

Choice B:

Encouraging deep breathing and coughing exercises. This is an incorrect intervention because it may increase dyspnea and fatigue in a patient with COPD who already has difficulty breathing. Instead, the nurse should teach pursed-lip breathing and diaphragmatic breathing techniques to improve gas exchange and reduce air trapping.

Choice C:

Administering bronchodilators and corticosteroids as ordered. This is a correct intervention because these medications help to relax the smooth muscles of the airways, reduce inflammation, and improve airflow in a patient with COPD.

Choice D:

Providing supplemental oxygen via nasal cannula as ordered. This is a correct intervention because oxygen therapy helps to correct hypoxemia, reduce pulmonary hypertension, and improve exercise tolerance and quality of life in a patient with COPD. The nurse should monitor the oxygen saturation and adjust the flow rate according to the prescription and the patient's response.

Choice E:

Restricting fluid intake to prevent fluid overload. This is an incorrect intervention because fluid restriction is not indicated for a patient with COPD unless there is evidence of heart failure or renal impairment. Adequate hydration helps to thin the secretions and facilitate expectoration in a patient with COPD. The nurse should encourage oral fluids unless contraindicated and monitor the fluid balance and electrolytes of the patient.

Choice A reason:

The client's level of fatigue and weakness is an important data to collect because fatigue is one of the most common and disabling symptoms of MS, affecting about 80% of people with the condition. Fatigue can interfere with the client's daily activities, quality of life, and ability to cope with other symptoms. Weakness is also a common symptom of MS, caused by damage to the nerve fibers that control muscle movements. Weakness can affect the client's mobility, balance, and coordination.

Choice B reason:

The client's cognitive and emotional status is another important data to collect because MS can affect the brain and spinal cord, leading to cognitive impairment in about 50% of people with MS. Cognitive impairment can affect the client's memory, attention, concentration, problem-solving, and decision-making skills. MS can also cause emotional changes, such as depression, anxiety, mood swings, irritability, and euphoria. Emotional changes can affect the client's coping skills, social relationships, and self-esteem.

Choice C reason:

The client's family history and genetic risk factors is not an important data to collect because MS is not a hereditary disease. Although genetic factors may play a role in increasing the susceptibility to MS, they are not sufficient to cause the disease by themselves. MS is thought to be caused by a combination of genetic and environmental factors that trigger an autoimmune response in the central nervous system. Therefore, knowing the client's family history and genetic risk factors will not help in diagnosing or managing MS.

Choice D reason:

The client's vision and hearing acuity is an important data to collect because MS can affect the optic nerve and cause visual disturbances, such as blurred vision, double vision, loss of color vision, pain in the eye, or temporary blindness. Visual disturbances are often the first symptom of MS and can recur or worsen over time. MS can also affect the auditory nerve and cause hearing problems, such as hearing loss, tinnitus, or vertigo. Hearing problems are less common than visual problems in MS but can still affect the client's communication and quality of life.

Choice E reason:

The client's mobility and coordination skills is an important data to collect because MS can damage the nerve fibers that control muscle movements and cause spasticity, tremors, ataxia, dysmetria, or dysdiadochokinesia. These symptoms can affect the client's mobility and coordination skills and increase the risk of falls, injuries, or disability. Assessing the client's mobility and coordination skills can help in planning interventions to improve function, safety, and independence.

Choice A reason:

Asking about the clients' current exercise habits helps the nurse to assess their baseline physical activity levels, their preferences, their strengths, and their areas for improvement. This information can help the nurse to tailor the health promotion interventions to the clients' needs and goals.

Choice B reason:

Asking about the benefits of regular physical activity helps the nurse to evaluate the clients' knowledge and awareness of the positive effects of exercise on their health and well-being. This information can help the nurse to reinforce the clients' motivation and provide education as needed.

Choice C reason:

Asking about the barriers to increasing physical activity helps the nurse to identify the factors that may prevent or hinder the clients from engaging in exercise. These factors may include lack of time, resources, support, or confidence. This information can help the nurse to address the clients' concerns and challenges and help them find solutions.

Choice D reason:

Asking about the strategies to overcome the barriers helps the nurse to empower the clients to take action and make changes in their behavior. The nurse can help the clients to develop realistic and specific plans that suit their abilities and preferences. The nurse can also provide support and encouragement along the way.

Choice E reason:

Asking about the potential complications of physical inactivity is not a relevant question to assess the clients' readiness for enhanced fitness. This question may be appropriate for secondary or tertiary prevention, but not for primary prevention. Primary prevention focuses on promoting health and preventing disease or injury, not on treating or rehabilitating existing problems.

Choice A reason:

A well-written outcome should be specific, meaning it should clearly state what is expected to be achieved, by whom, and under what conditions. A specific outcome helps to focus the actions and resources needed to accomplish it. For example, an outcome that states "Students will improve their writing skills”. is too vague and does not specify how the improvement will be measured or what level of improvement is expected. A more specific outcome would be "Students will demonstrate an increase in their average writing score by 10% on the final exam.".

Choice B reason:

A well-written outcome should also be measurable, meaning it should have a quantifiable indicator that can be used to assess the progress and achievement of the outcome. A measurable outcome helps to determine whether the outcome has been met or not, and to what extent. For example, an outcome that states "Students will enjoy the course”. is not measurable because it does not have a clear criterion for evaluating the students' satisfaction. A more measurable outcome would be "At least 80% of the students will rate the course as satisfactory or higher on the course evaluation survey.".

Choice C reason:

Another characteristic of a well-written outcome is that it should be realistic, meaning it should be achievable within the given time frame, resources, and constraints. A realistic outcome helps to set reasonable expectations and avoid frustration or disappointment. For example, an outcome that states "Students will master all the topics covered in the course”. is not realistic because it is too ambitious and unrealistic for a single course. A more realistic outcome would be "Students will demonstrate proficiency in at least 75% of the topics covered in the course.".

Choice D reason:

Finally, a well-written outcome should be time-bound, meaning it should have a specific deadline or target date for completion. A time-bound outcome helps to create a sense of urgency and motivation, and to monitor the progress and results of the outcome. For example, an outcome that states "Students will apply their knowledge to real-world problems”. is not time-bound because it does not indicate when or how often the students will do so. A more time-bound outcome would be "By the end of the semester, students will complete at least two projects that require them to apply their knowledge to real-world problems.".

Choice E reason:

A well-written outcome should not be broad, meaning it should not be too general or vague that it does not provide any guidance or direction for action. A broad outcome makes it difficult to plan, implement, and evaluate the outcome. For example,.

Choice A reason:

The nurse checks the client's identification bracelet and verifies allergies. This is an essential component of this skill because it ensures that the nurse is performing the intervention for the right client and avoids any potential adverse reactions or interactions due to allergies.

Choice B reason:

The nurse measures the client's blood pressure in both arms and compares with previous readings. This is not an essential component of this skill because it is not directly related to the intervention for hypertension. It is a part of the assessment process that should be done before planning the intervention.

Choice C reason:

The nurse asks the client if they have taken any over-the-counter medications or herbal supplements. This is an essential component of this skill because it helps the nurse to identify any possible factors that may affect the client's blood pressure or the effectiveness of the intervention. Some medications or supplements may interact with the prescribed drugs or alter the blood pressure level.

Choice D reason:

The nurse reviews the most current evidence and guidelines for hypertension management. This is not an essential component of this skill because it is not specific to the client's situation or needs. It is a part of the planning process that should be done before implementing the intervention.

Choice E reason:

The nurse explains the purpose, procedure, and potential side effects of the intervention to the client. This is an essential component of this skill because it respects the client's autonomy and informed consent. It also helps the client to understand what to expect and how to cope with any possible complications or discomforts.

Choice A reason:

The date and time of the evaluation are essential to document because they provide a reference point for the progress of the patient and the effectiveness of the nursing interventions. They also help to establish a timeline of events and facilitate communication among the health care team.

Choice B reason:

The methods used to measure outcomes are important to document because they show how the nurse assessed the patient's condition and whether the expected outcomes were met, partially met, or not met. They also provide evidence of the quality and consistency of care provided by the nurse.

Choice C reason:

The revisions made to the plan of care are necessary to document because they reflect the changes in the patient's status and needs, as well as the nurse's clinical judgment and decision making. They also demonstrate the ongoing evaluation and adaptation of the nursing care plan to achieve optimal outcomes for the patient.

Choice D reason:

The rationale for choosing interventions is not required to document because it is part of the planning phase of the nursing process, not the evaluation phase. The rationale for choosing interventions should be based on evidence-based practice, standards of care, and clinical guidelines, which are already established and available for reference.

Choice E reason:

The comparison of outcomes with goals is essential to document because it shows whether the nursing care plan was effective in addressing the patient's problems and improving the patient's condition. It also helps to identify areas of improvement, gaps in care, and opportunities for learning and feedback.

Choice A reason:

The client's readiness and motivation to change are crucial factors for the success of CBT, as it requires active participation and homework assignments from the client. CBT is based on the premise that changing maladaptive thoughts and behaviors can improve emotional well-being. Therefore, the client needs to be willing and able to engage in this process and apply the learned skills to their daily life.

Choice B reason:

The availability and accessibility of CBT services are also important factors for the success of CBT, as they determine how often and how easily the client can receive the therapy. CBT is typically delivered in a time-limited and structured manner, with sessions ranging from 8 to 20 weeks. The client needs to have regular access to a qualified CBT therapist who can provide consistent and evidence-based treatment.

Choice C reason:

The cost and duration of CBT sessions are not relevant factors for the success of CBT, as they do not directly affect the quality or effectiveness of the therapy. CBT is generally considered to be a cost-effective and efficient intervention for anxiety disorders, as it can produce lasting benefits in a relatively short period of time. The cost and duration of CBT sessions may affect the client's preference or adherence to the therapy, but they are not essential for its outcome.

Choice D reason:

The compatibility and rapport between the client and therapist are vital factors for the success of CBT, as they influence the therapeutic alliance and the client's trust in the therapist. CBT is a collaborative and goal-oriented therapy that requires a strong working relationship between the client and therapist. The client needs to feel comfortable and supported by the therapist, who can provide empathy, feedback, guidance, and encouragement.

Choice E reason:

The evidence base and efficacy of CBT for anxiety disorders are significant factors for the success of CBT, as they demonstrate the validity and reliability of the therapy. CBT is one of the most researched and empirically supported psychological interventions for anxiety disorders, with numerous studies showing its superiority over other treatments or placebo. The client can benefit from knowing that CBT is based on sound scientific principles and proven techniques.