Which of the following is an example of an intervention used in the Prob-lem-Intervention-Evaluation documentation method?
1. Risk for injury related to falling due to dizziness
2. Client fell while walking to bathroom unassisted
3. Client continues to report periods of dizziness upon sitting up
4. Educated to the purpose of dangling on the bedside before standing
ANS: 4
The problem is reflected by a nursing diagnosis while the interventions are related to nursing ac-tions directed toward minimizing or eliminating the problem. The evaluation is the client's objec-tive or subjective response to the nursing intervention.
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The nurse is assessing a client for spiritual distress. Which observations indicate that a client is experiencing spiritual distress?
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When assessing a child for any possible cardiac anomalies, the nurse takes the right arm blood pressure (BP) and the BP in one of the legs. She finds that the right arm BP is greater than that found in the child's leg
The nurse reacts to these findings in which of the following ways? a. charts the findings and realizes they are normal b. suspects the child may have coarctation of the aorta c. places the child in the Trendelenburg position d. notifies the physician and alerts the surgery team
____________________ care is a form of therapy designed to maintain the patient's highest state of wellness.
Fill in the blank(s) with the appropriate word(s).