The nurse is assessing a patient according to interventions provided in the nursing care plan. This nurse is conducting which of the following types of assessments?
a. Comprehensive c. Focused
b. Ongoing d. Emergency
B
An ongoing assessment is an assessment that includes systematic monitoring and observation related to specific problems. Ongoing assessments are done when problems have been identified and a plan of care has been implemented to address these problems.
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The nurse is assessing the patient's pain using the Critical Care Pain Observation Tool. Which of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention?
a. Absence of vocal sounds b. Fighting the ventilator c. Moving legs in bed d. Relaxed muscles in upper extremities
A patient diagnosed with depression tells the nurse, "I've been supplementing my paroxetine (Paxil) with St. John's wort, and it has helped a great deal." What is the nurse's priority action?
a. Assess changes in the patient's level of depression. b. Remind the patient to use a secondary form of birth control. c. Educate the patient about the risks of serotonin syndrome. d. Suggest adding valerian to the treatment regimen to further improve results.
Which of the following is not considered to be a barrier to creative thinking?
a. fear of making mis-takes c. hasty decision mak-ing b. open mindset d. stereotypical percep-tion of client care
At what phase of group development would the nurse hear the following interchange? Client 1: "I do not feel comfortable here." Client 2: "I wonder what we are supposed to talk about." Client 3: "Let's ask the leader to explain things again."
A. Preorientation B. Orientation C. Working D. Termination