A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first by
a. Asking physical therapy to assist the patient because of the new injuries.
b. Disregarding all previous diagnoses and establishing a new plan of care.
c. Reassessing the patient.
d. Setting new priorities for the patient.
ANS: C
The nurse needs to reassess the patient after any type of change in health status. The nursing process is dynamic and ongoing. Asking physical therapy to assist the patient is premature before reassessing the patient and awaiting physician orders. The nurse may not need to disregard all previous diagnoses. Some diagnoses may still apply, but the patient needs to be reassessed first. Setting new priorities is not recommended before assessment and establishing diagnoses.
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