The nurse is reviewing the care plan for a client with schizophrenia
Upon assessment the client admits to hearing voices that say, "Kill yourself." The nurse documents the client is at risk for injury and includes the following statement in the plan of care, "Client will not harm self during hospitalization." Which step of the nursing process is the nurse using?
1. Goal setting.
2. Implementation.
3. Diagnosis.
4. Evaluation.
Correct Answer: 1
Goal setting occurs after a diagnosis has been formulated. The statement written is a goal for the client during hospitalization. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. The diagnosis is formulated after data have been collected, and goal setting occurs after a diagnosis has been formulated. Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. The nurse's recorded observations indicate the goals of the nursing care plan have been achieved.
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