Nokea
A patient admitted with right leg thrombophlebitis is to be discharged from an acute-care facility. Following treatment with a heparin infusion, the nurse notes that the patients leg is pain-free, without redness or edema. Which step of the nursing process does this reflect?
- A. Diagnosis
- B. Analysis
- C. Implementation
- D. Evaluation
Correct Answer: D
Rationale: The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the care plan into action. This nurses actions do not constitute diagnosis.
You may also like to solve these questions
Your older adult patient has a diagnosis of rheumatoid arthritis (RA) and has been achieving only modest relief of her symptoms with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). When creating this patients plan of care, which nursing diagnosis would most likely be appropriate?
- A. Self-care deficit related to fatigue and joint stiffness
- B. Ineffective airway clearance related to chronic pain
- C. Risk for hopelessness related to body image disturbance
- D. Anxiety related to chronic joint pain
Correct Answer: A
Rationale: Nursing diagnoses are actual or potential problems that can be managed by independent nursing actions. Self-care deficit would be the most likely consequence of rheumatoid arthritis. Anxiety and hopelessness are plausible consequences of a chronic illness such as RA, but challenges with self-care are more likely. Ineffective airway clearance is unlikely.
A terminally ill patient you are caring for is complaining of pain. The physician has ordered a large dose of intravenous opioids by continuous infusion. You know that one of the adverse effects of this medicine is respiratory depression. When you assess your patients respiratory status, you find that the rate has decreased from 16 breaths per minute to 10 breaths per minute. What action should you take?
- A. Decrease the rate of IV infusion.
- B. Stimulate the patient in order to increase respiratory rate.
- C. Report the decreased respiratory rate to the physician.
- D. Allow the patient to rest comfortably.
Correct Answer: C
Rationale: End-of life issues that often involve ethical dilemmas include pain control, do not resuscitate orders, life-support measures, and administration of food and fluids. The risk of respiratory depression is not the intent of the action of pain control. Respiratory depression should not be used as an excuse to withhold pain medication for a terminally ill patient. The patients respiratory status should be carefully monitored and any changes should be reported to the physician.
The nursing instructor cites a list of skills that support critical thinking in clinical situations. The nurse should describe skills in which of the following domains?
- A. Self-esteem
- B. Self-regulation
- C. Inference
- D. Autonomy
- E. Interpretation
Correct Answer: B,C,E
Rationale: Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Self-esteem and autonomy would not be on the list because they are not skills.
A student nurse has been assigned to provide basic care for a 58-year-old man with a diagnosis of AIDS-related pneumonia. The student tells the instructor that she is unwilling to care for this patient. What key component of critical thinking is most likely missing from this students practice?
- A. Compliance with direction
- B. Respect for authority
- C. Analyzing information and situations
- D. Withholding judgment
Correct Answer: D
Rationale: Key components of critical thinking behavior are withholding judgment and being open to options and explanations from one patient to another in similar circumstances. The other listed options are incorrect because they are not components of critical thinking.
An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The patient is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurses action is an example of which therapeutic communication technique?
- A. Informing
- B. Suggesting
- C. Expectation-setting
- D. Enlightening
Correct Answer: A
Rationale: Informing involves providing information to the patient regarding his or her care. Suggesting is the presentation of an alternative idea for the patients consideration relative to problem solving. This action is not characterized as expectation-setting or enlightening.