A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
ANS: A
During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
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The nurse in an acute care facility is caring for a patient recovering from a cerebral vascular accident that has resulted in a mild loss of muscle function in his right arm and leg
The nurse is best addressing the patient's need via the functional model of care when: a. assessing the patient's right-sided muscle strength daily. b. reaffirming to the patient that physical therapy will improve his muscle strength. c. instructing the patient's family on how to properly assist the patient in walking. d. placing the telephone where the patient can reach it with his left hand.
The nurse massages the patient to promote relaxation. Which is a suitable intervention for the nurse to implement during the massage?
a. Use the friction technique over the spine. b. Assess for pain, anxiety, and discomfort. c. Instruct the patient to sit upright and for-ward. d. Knead the patient's scalp with warm lo-tion.
After completing an assessment and discussing the plan of care with the family, upon which one member might the nurse focus effort?
A. The adult patient with the acute flare-up of chronic illness B. The child who, being young, was energetic and enthusiastic C. The extended family, who had to learn to become a resource D. The spouse, who was flexible and able to cope
The duration of the PR interval on an electrocardiogram (ECG) reflects the time required for:
A. conduction from the atrioventricular (AV) node to the sinoatrial (SA) node. B. conduction from the sinoatrial (SA) to the atrioventricular (AV) node. C. depolarization and conduction through the ventricles. D. depolarization and repolarization of the ventricles.