The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority?
a. Call the rapid response team.
b. Ask the patient to rate and describe the pain.
c. Raise the head of the bed.
d. Administer pain relief medications.
ANS: B
The nurse's ability to establish a nursing diagnosis, plan and implement care, and evaluate the effectiveness of care depends on an accurate and timely assessment. The other responses are all interventions; the nurse cannot know which intervention is appropriate until the nurse completes the assessment, makes a nursing diagnosis, and plans care.
You might also like to view...
When providing care to a client taking isoniazid (INH), the nurse would monitor the client carefully for which of the following that indicate toxicity? Select all that apply
A) Peripheral neuropathy B) Visual changes C) Nausea D) Vomiting E) Hepatitis
You are doing the initial assessment on a new patient admitted because he developed a growth on his face
The patient states that he has ataxia-telangiectasis. You know that this is an autosomal recessive neurodegenerative disorder with a defect in chromosome 11. Based on the patient's diagnosis what would you suspect? A) He has developed an infection. B) He has Bell's palsy. C) He has a type of skin cancer. D) He will need radiation treatments.
The nurse is assessing a client and notes that she is lacking eyebrow hair and eyelashes. The nurse suspects:
a. the client was a victim of a house fire caused by cigarette smoking. b. this is related to abuse of marijuana. c. the client smokes crack cocaine. d. this is caused by heroin injections.
Neuman defined ________ broadly as "all internal and external factors or influences surrounding the identified client or client system
A. Ecosystem B. Environment C. Wellness D. Nursing