The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult?
A. Formulate a nursing diagnosis of impaired gas exchange
B. Record in the medical record the distance a client ambulate in the hall
C. Write individualized nursing orders in the care plan
D. Compare client responses to the desired outcomes for pain relief
Ans: B. Record in the medical record the distance a client ambulate in the hall
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The nurse is assessing a male patient diagnosed with chronic heart failure 10 years ago. Which finding would indicate poor perfusion to the tissues?
a. Blood pressure reading of 102/64 b. Absence of hair on the lower legs and feet c. Pulse rate of 104 beats/min d. Shortness of breath when supine
Humanistic theories are important to health care because these theories serve as the foundation for the concept of:
a. Assertiveness training b. Behaviorism c. Holistic care d. Behavior modification
A patient, seen laughing and talking with visitors, asks the nurse for pain medication. Which of the following responses would demonstrate the nurse is functioning within the component of conscious nursing care?
1. Provide the medication as requested and according to organizational policies. 2. Wait until the patient's visitors have left the room and then provide the medication. 3. Provide the medication along with other prescribed medications several hours later. 4. Ask the visitors to leave the room and discuss the patient's pain level before providing the medication.
Paraplegia is paralysis and loss of sensory function:
a. In the arms b. In the legs c. From the chest up d. From the neck down