The nurse is reviewing the plan of care for a client who was admitted for suicidal tendencies. The nurse documents that the client is no longer experiencing thoughts of hurting self. Which step of the nursing process is the nurse using?
1. Implementation.
2. Evaluation.
3. Planning.
4. Assessment.
Correct Answer: 2
Evaluation is the process whereby the progress toward achieving the goals is reviewed and documented. Implementation is the process of performing certain interventions designed to move the client toward achievement of the goal. During the planning phase of the nursing process, nursing diagnoses are formulated after data have been assessed, and then goal setting takes place. Assessment is the process by which data are collected.
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The prehospital nurse is screening victims of a store robbery that resulted in several people being injured. Of those injured, the nurse should encourage which of the following to seek additional care at the nearest emergency department?
1. Elderly male who was knocked unconscious 2. Teenage female who took cover under a shelving unit 3. Middle-age female who crouched down in a corner of the room 4. Male in his mid-20s who had several light boxes of products fall on him while the robbers ran through the store
Vicarious trauma is a phenomenon nurses might experience. What are the signs indicating this problem that the nurse should be aware of? Note: Credit will be given only if all correct and no incorrect choices are selected. Select all that apply
1. Reduced sense of accomplishment 2. A positive effect on commitment to one's work 3. Questioning of personal belief systems 4. Balance of time for family, self, friends, and work 5. Frustration with the judicial system
Which statement best describes the pathophysiology of multiple organ dysfunction syndrome (MODS) in a patient with sepsis?
1. The primary cause of MODS is decreased blood pressure. 2. Endothelial dysfunction is a primary cause of MODS. 3. Increased microvascular bleeding causes MODS. 4. Circulating pathogens cause destruction of organs, resulting in MODS.
Persons who wander may not rest when they become fatigued.
Answer the following statement true (T) or false (F)