Fundamentals of Nursing Q 209

Correct Answer: D. Evaluation

During the implementation phase, the nurse carries out the interventions or delegates them to other health care team members. During the evaluation phase, the nurse judges whether her actions have been successful in treating or preventing the identified client health problem. This final step of the nursing process is vital to a positive patient outcome. Whenever a healthcare provider intervenes or implements care, they must reassess or evaluate to ensure the desired outcome has been met. Reassessment may frequently be needed depending upon overall patient condition. The plan of care may be adapted based on new assessment data.

Option A: In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase. 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 B: In the diagnosis phase, the nurse identifies the client’s health status. The North American Nursing Diagnosis Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual or potential health problems on the part of the patient, family or community.

Option C: In the planning outcomes phase, the nurse and client decide on goals they want to achieve. In the intervention planning phase, the nurse identifies specific interventions to help achieve the identified goal. 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.