Which of the following is not a step in the nursing process?
a. Assessment
b. Nursing diagnosis
c. Physician orders
d. Planning
C
The nursing process starts with assessment (response A). During assessment, the information regarding the patient is collected and then organized according to patient-centered problems and nursing diagnoses (response B). After problems are identified, the plan (response D) is developed. Physician orders are considered in the plan of care but are not a step in the nursing process.
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The nurse must inform an older adult who does not speak English about patient rights. Also, the nurse has to have the adult sign the document about information access
Which intervention should the nurse use to maintain the confidentiality of this older adult? a. Present the patient with a Spanish version of the information access document. b. Have an English-speaking family member to explain the document to the patient. c. Explain the document to the patient using an interpreter to ensure understanding. d. Instruct an interpreter to read the information access document to the resident privately.
If a family member makes suggestions or gives directions about the way to care for a resident, the nursing assistant should
a. accept the suggestions that are within your scope of duty. b. ignore the suggestions. c. tell the family that their ideas are not in the care plan. d. ask the family to do the care themselves.
The nurse is caring for a patient who is having constant nociceptor pain. Which intervention best addresses the patient's pain during the perception phase of pain?
a. Administer nonsteroidal anti-inflammatory drugs (NSAIDs) for moderate pain. b. Ask the physician if an opioid could be ordered to treat the patient's pain when severe. c. Engage the patient in conversation re-garding his family, hobbies, and plans following discharge from the facility. d. Determine if the patient typically takes a neurotransmitter uptake blocker medica-tion for pain control.
Which of the following is NOT a symptom of venous thrombosis/pulmonary embolism?
A. Shortness of breath or unexplained coughing B. Bluish discoloration of the skin C. Severe cramping in the legs and arms D. Pleuritic chest pain