After completing a thorough database and carrying out nursing interventions based on priority diagnoses, the nurse proceeds to which step of the nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
D
In the five-step nursing process, evaluation is the last step following assessment, diagnosis, planning, and intervening. Assessment involves gathering information about the patient. Next, nursing diagnoses are determined. During the planning phase, patient outcomes are determined. Implementation involves carrying out appropriate nursing interventions.
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The nurse is caring for an individual who has a tension headache. Which of the following would be included in the patient's plan of care? (Select all that apply.)
a. Dark glasses b. Massage c. Moist heat d. Aerobic exercise e. Cold compresses f. Ergotomine
Stage C patients usually require a combination of three to four drugs to manage their heart failure. In addition to ACE inhibitors and beta blockers, diuretics may be added. Which of the following statements about diuretics is NOT true?
1. Diuretics reduce preload associated with fluid retention. 2. Diuretics can be used earlier than stage C when the goal is control of hypertension. 3. Diuretics may produce problems with electrolyte imbalances and abnormal glucose and lipid metabolism. 4. Diuretics from the potassium-sparing class should be used when using an angiotensin receptor blocker (ARB).
In which of the following situations would the nurse be most justified in implementing trial-and-error problem solving?
A) The nurse is attempting to landmark an obese client's apical pulse. B) The nurse is attempting to determine the range of motion of a client's hip joint following hip surgery. C) The nurse is attempting to determine which PRN (as needed) analgesic to offer a client who is in pain. D) The nurse is attempting to determine whether a poststroke client has a swallowing deficit.
The nurse assessing a 12-1/2-year-old child asks the child about siblings. This preteen tells the nurse that there has been recent conflict and less support from a sibling close in age
The nurse realizes that at this age this perceived decrease in support and increased conflict: a. is reaching a peak and is not unusual b. is possibly due to watching too much violence on television c. has to do with caregivers treating the children differently d. is a sign of impending lifelong relationship problems