The nurse is caring for a confused client. The nurse informs the client of the date, day of the week, time, and location each time the room is entered. The nurse is utilizing which step of the nursing process?
1. Implementation
2. Evaluation
3. Planning
4. Assessment
1
Rationale 1: Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. A confused client needs reorientation as part of the nursing care provided.
Rationale 2: Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented.
Rationale 3: During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place.
Rationale 4: Assessment is the phase of obtaining subjective and objective data about the client.
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