A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. This is the first step in the problem-oriented approach as it helps the nurse understand the immediate issues and prioritize data collection. By focusing on the presenting situation, the nurse can gather relevant information efficiently. A: Completing questions in chronological order may not address the current problem effectively. C: Making accurate interpretations of the data comes after data collection, not as the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to guide what observations are necessary.

Correct Answer: B

Rationale: The correct answer is B - Focus on the patient's presenting situation. This is because in the problem-oriented approach, the nurse must first gather data related to the patient's current issue or concern. This initial focus helps in identifying the primary problem, setting priorities, and developing a care plan. Now, let's analyze the other choices: A: Completing questions in chronological order may not be necessary or relevant to addressing the patient's immediate issue. C: Making accurate interpretations of the data comes after data collection, so it is not the first step. D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific and relevant data.

Correct Answer: D

Rationale: The correct answer is D: To help nurses focus on the scope of medical practice. Developing a standard formal nursing diagnosis helps nurses to identify and focus on the patient's specific health issues within the nursing scope of practice. This enables nurses to provide targeted and effective care interventions. A: To form a language that can be encoded only by nurses - This choice is incorrect because the purpose of a nursing diagnosis is not exclusive to nurses and should be comprehensible to all healthcare professionals caring for the patient. B: To distinguish the nurse’s role from the physician’s role - While this distinction is important, the main purpose of developing a nursing diagnosis is to guide nursing interventions based on the patient's nursing care needs, rather than solely differentiating roles. C: To develop clinical judgment based on other’s intuition - This choice is incorrect as clinical judgment should be based on evidence-based practice and critical thinking, rather than solely relying on intuition or others' opinions.

Correct Answer: C

Rationale: The correct next step after identifying nursing diagnoses is planning. Planning involves setting goals and creating a plan of care to address the patient's needs based on the identified nursing diagnoses. This step helps in determining interventions and outcomes for the patient. Assessment has already been completed, and diagnosis is the step where nursing diagnoses are identified. Implementation comes after planning, where the nurse carries out the planned interventions. Therefore, the logical next step in the nursing process after identifying nursing diagnoses is planning.

Correct Answer: C

Rationale: The correct answer is C: Implementation. In this step of the nursing process, the nurse is carrying out the care plan based on the identified nursing diagnoses. The nurse is actively providing care and interventions to meet the patient's needs. Assessment (A) is the initial step where data is collected and analyzed. Planning (B) is where goals and interventions are determined based on assessment findings. Evaluation (D) is the final step where the nurse assesses the effectiveness of the care provided. In this scenario, the nurse has already completed the care plan and is now executing the plan by implementing the interventions, making choice C the correct answer.