The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
ANS: A
During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
You might also like to view...
The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the tongue. Which question to the client is most appropriate based on this initial data?
1. "Have you eaten licorice lately?" 2. "How often do you brush your tongue?" 3. "Have you recently taken antibiotics?" 4. "Have you ever had this happen before?"
A patient is taking a calcium channel blocker (CCB) for stable angina. The patient's spouse asks how calcium channel blockers relieve pain. The nurse will explain that CCBs:
a. help relax peripheral arterioles to reduce afterload. b. improve coronary artery perfusion. c. increase the heart rate to improve myo-cardial contractility. d. increase the QT interval.
Which helps to keep the hair and skin soft and shiny?
a. The dermis and epidermis b. The chromosomes c. The sweat glands d. The oil glands
In which of the following occupations would liver disease be more likely?
1. Agricultural workers 2. Dry cleaners 3. Embalmers 4. Insulators