The nurse should include which factor(s) in a pain assessment? (Select all that apply.)
a. What provokes it
b. Location
c. Race
d. Severity
e. Frequency
ANS: A, B, D, E
A patient's race would not be included in a pain assessment. All other options are significant parts of a pain assessment.
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A patient with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the patient's plan of care?
A) Impaired physical mobility related to presence of an indwelling urinary catheter B) Risk for infection related to presence of an indwelling urinary catheter C) Toileting self-care deficit related to urinary catheterization D) Disturbed body image related to urinary catheterization
A nurse is using a structured care methodology that follows a set of steps based on a clinician's decision process to help standardize nursing care plans. What is the term for this element of a structured care methodology?
A) algorithm C) standard of care B) national guidelines D) clinical practice guideline
Which of the following would a community health nurse identify as most important to sending skills involved with communication?
A) Active listening B) Paraphrasing C) Nonverbal messages D) Rapport
Gastric juices are released during the gastric phase when the ________.
A. adrenergic receptors on parietal cells are stimulated. B. stomach distends. C. brain receives sensory input. D. chyme or partially digested foods enter the intestine.