A client comes to the emergency department complaining of severe chest pain. The nurse asks the client questions and takes vital signs. Which step of the nursing process is the nurse demonstrating?
A) Assessing
B) Diagnosing
C) Planning
D) Implementing
Ans: A
Assessing is the step in which nurses assess the client to determine the need for nursing care. When assessing, the nurse systematically collects client data.
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While conducting a breast health history, a patient states that there is "nothing to say"
about the breasts and then makes a comment about not realizing that it would take so many months for the milk to stop flowing in the breasts after having a baby. What should the nurse respond to the patient? A) "It can take up to a year for the milk to stop flowing." B) "Is it painful?" C) "In which breast does this occur?" D) "Are there any other symptoms occurring at this time?"
A teen African American has been prescribed azelaic acid (Azelex) for severe acne. What education about this medication would be most important for the teen to know?
a. Azelaic acid may reduce pigmentation in dark-skinned people. b. Azelaic acid is more effective than other acne medications. c. The risk of allergy is higher for azelaic acid than it is for other acne medications. d. Azelaic acid has been determined to have significant systemic toxicity.
The family of a patient with third-degree burns wants to know why "the scabs are being cut off" the patient's leg. What is the most appropriate response by the nurse?
1. "The scabs are really old burned tissue and need to be removed to promote healing." 2. "I'll ask the doctor to come and talk with you about the treatment plan." 3. "The patient asked for the scabs to be removed." 4. "The scabs are removed to check for blood flow to the burned area."
What is the purpose of the color-coded wedges on the Intervention Wheel?
a. The interventions are grouped together in related wedges. b. The wedges consist of referral information for each wedge. c. The element of health teaching is the predominant feature of each wedge. d. Coalition building must be implemented with each wedge.