What is the main purpose of the assessment phase of the nursing process?
A. To set goals for the patient's recovery
B. To validate and document patient data
C. To use appropriate nursing interventions
D. To evaluate the success of patient outcomes
Ans: B. To validate and document patient data
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What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?
a. The medication should be given on an empty stomach. b. Insomnia can be a significant side effect. c. Gums should be massaged regularly to prevent hyperplasia. d. Blood pressure should be closely monitored.
Based on this description, what is the most likely diagnosis?
A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. A) Conjunctivitis B) Acute iritis C) Corneal abrasion D) Subconjunctival hemorrhage
The nurse monitors the urine output of a postoperative patient. What condition does urine output indicate?
A) Tissue perfusion B) Kidney failure C) Lung capacity D) Clot formation
Both individual and familial factors related to violence must be assessed within the context of the larger community. A community characteristic for violence is:
1. Multiple changes of residence for a family 2. High crime rate 3. Social isolation 4. Substance abuse