When modifying a care plan to meet a client whose status has changed significantly over the past few days, the nurse should:
1. Redevelop the entire client care plan
2. Focus on changing the nursing diagnoses and goals
3. Perform a complete reassessment of all client factors
4. Add more nursing interventions from a standardized plan of care
ANS: 3
A complete reassessment of all client factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. After reassessment the nurse will determine what components of the care plan are accurate for the situation. It may not require redoing the entire care plan. The nurse should not only focus on the nursing diagnoses and goals that have changed. Interventions may also need revising to meet new goals. Adding more nursing interventions may or may not be necessary. The nurse adjusts interventions on the basis of the client's response and previous expe-rience with similar clients. Standards of care are used to determine whether the right interven-tions have been chosen or whether additional ones are required.
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