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In which step of the nursing process does the nurse determine the appropriate interventions for the identified nursing diagnosis?
- A. Planning
- B. Evaluation
- C. Assessment
- D. Intervention
Correct Answer: A
Rationale: In the nursing process, planning is the step where the nurse determines the appropriate interventions for the identified nursing diagnosis. Firstly, after assessing the patient's needs (Assessment), the nurse analyzes the data to identify nursing diagnoses. Next, in the Planning step, the nurse sets goals, establishes priorities, and decides on specific interventions to address the nursing diagnoses. This step involves developing a comprehensive care plan tailored to the individual patient's needs. Evaluation comes after the interventions are implemented to assess the effectiveness of the care provided. The Intervention step involves carrying out the planned interventions. Thus, the correct answer is A: Planning.
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The nurse is arranging education for the menopausal support group regarding the approaches to treat the symptoms. Which of the following would be components of current treatments? Select all that apply.
- A. Moderately intense exercises
- B. Balanced diet, rich in calcium
- C. Alternative medicine such as black cohosh
- D. Over-the-counter sleep aid
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Moderately intense exercises help manage menopausal symptoms by reducing hot flashes and improving mood.
2. Exercise also helps in maintaining bone health and reducing the risk of osteoporosis.
3. Physical activity promotes overall well-being and can alleviate symptoms like weight gain and insomnia.
Summary of why other choices are incorrect:
B. While a balanced diet rich in calcium is important for overall health, it is not a primary component of treating menopausal symptoms.
C. Alternative medicine like black cohosh may have some benefit, but evidence is inconclusive and not widely recommended.
D. Over-the-counter sleep aids may help with sleep disturbances, but they do not address the holistic management of menopausal symptoms.
A nurse is entering information on the patient’s electronic health record (EHR) and is called to assist in an emergency situation with regard to another patient in the labor and birth suite. The nurse rushes to the scene to assist; however, she leaves the chart open on the computer screen. The emergent patient situation is resolved satisfactorily, and the nurse comes back to the computer entry screen to complete charting. At the end of the shift, the nurse manager asks to speak with the nurse and tells her that she is concerned with what happened today on the unit because there was a breach in confidentiality. Which response by the nurse indicates that she understands the nurse manager’s concerns?
- A. The nurse acknowledges that she should have made sure that her patient was safe before assisting with the emergency.
- B. The nurse states that she should have logged out of the EHR prior to attending to the emergency.
- C. The nurse indicates that the unit was understaffed.
- D. The nurse indicates that the she changed her password following the clinical emergency to maintain confidentiality.
Correct Answer: B
Rationale: Step-by-step rationale:
1. The correct answer is B because logging out of the EHR prior to attending to the emergency is crucial to maintain patient confidentiality.
2. By leaving the EHR open, the nurse exposed sensitive patient information to potential unauthorized access.
3. This action violates patient privacy rights and is a breach of confidentiality.
4. Choice A is incorrect as it does not address the specific issue of breaching patient confidentiality by leaving the EHR open.
5. Choice C is irrelevant as understaffing does not excuse the breach of patient confidentiality.
6. Choice D is incorrect as changing the password after the breach does not rectify the initial mistake of leaving the EHR open.
Summary: Choice B is the correct response as it directly addresses the breach of confidentiality by acknowledging the importance of logging out of the EHR to protect patient information. Choices A, C, and D are incorrect as they do not effectively address the issue of breaching patient confidentiality.
Which actions by the nurse indicate compliance with the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)
- A. The nurse posts an update about a patient on Facebook.
- B. The nurse gives the report to the oncoming nurse in a private area.
- C. The nurse gives information about the patient’s status over the phone to the patient’s friend.
- D. The nurse logs off any computer screen showing patient data before leaving the computer unattended.
Correct Answer: B
Rationale: The correct answer is B because giving the report to the oncoming nurse in a private area ensures patient information is shared securely, maintaining patient confidentiality as required by HIPAA. Posting patient updates on social media (A) violates patient privacy. Sharing patient information with a friend (C) breaches confidentiality. Leaving computer screens unattended with patient data visible (D) risks unauthorized access. B is the only choice that aligns with HIPAA regulations by prioritizing patient privacy and security.
The nurse is assessing a patient’s use of complementary and alternative therapies. Which should the nurse document as an alternative or complementary therapy practice? (Select all that apply.)
- A. Practicing yoga daily
- B. Drinking green tea in the morning
- C. Taking omeprazole (Prilosec) once a day
- D. Using aromatherapy during a relaxing bath
Correct Answer: A
Rationale: The correct answer is A: Practicing yoga daily. Yoga is considered a complementary therapy as it focuses on integrating the mind, body, and spirit for overall well-being. It is a holistic approach that complements traditional medical treatments.
- B: Drinking green tea in the morning is a healthy habit but not specifically categorized as a complementary or alternative therapy.
- C: Taking omeprazole is a conventional medication for acid reflux and not considered an alternative or complementary therapy.
- D: Using aromatherapy during a relaxing bath is a complementary therapy, but the question asked for alternative or complementary therapy practices, not both.
Which information regarding substance abuse is important for the nurse to understand?
- A. Cigarette smoking has little effect on maternity-related health.
- B. Women, ages 21 to 34 years, have the highest rates of specific alcohol-related problems.
- C. Coffee is a stimulant that has been related to birth defects.
- D. Prescription psychotherapeutic drugs do not affect the fetus.
Correct Answer: B
Rationale: Alcohol abuse during pregnancy has been associated with many negative outcomes. Cigarette smoking impairs fertility and causes low-birth-weight infants.