Many nursing diagnoses in the human response patterns:
a. evaluate the quality of care
b. determine whether the client is in danger
c. rely on the client's subjective evidence
d. evaluate the nurse-client communication process
C
Many nursing diagnoses in the human response patterns rely on the client's subjective evidence. This type of data cannot be directly assessed by the nurse through direct observation or any physical technique. Subjective data are statements made by the client regarding issues related to health and illness. For example, a client may state that he or she feels unable to cope with life or is having severe pain.
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A nurse is caring for a female patient who has developed atelectasis because of thick mucus secretions. The nurse is monitoring IV administration of acetylcysteine (Mucomyst) and notices that the patient's face is flushed
The appropriate nursing action would be to A) stop the administration of acetylcysteine. B) slow the administration of acetylcysteine and administer diphenhydramine if ordered. C) remove any residual drug from the patient's face. D) dilute the acetylcysteine solution.
A nurse who runs a pulmonary rehabilitation program wants to incorporate an educational component designed to facilitate patients' ownership of their own health. To accomplish this goal, the nurse would most likely create sessions based on
a. individual counseling. b. group discussions. c. lectures. d. role-playing.
The nurse is looking for the best interventions for postoperative pain control. When are the facility's policies and procedures an appropriate source of evidence?
a. When policies are based on high-quality clinical practice guidelines b. When evidence is derived from a valid and reliable quantitative research study c. When procedures originated from opinions of the facility's chief surgeon d. When evidence is founded on recommen-dations from experienced nurses
The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use?
a. Count the number of large squares in the R-R interval and divide by 300. b. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. c. Calculate the number of small squares between one QRS complex and the next and divide into 1500. d. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.