The nurse is talking with the parent of a child newly diagnosed with a chronic illness. The parent is upset and tearful. The nurse asks, "Whom do you talk to when something is worrying you?" This should be interpreted as:
a. inappropriate, because the parent is so upset.
b. a diversion of the present crisis to similar situations with which the parent has dealt.
c. an intervention to find someone to help the parent.
d. part of assessing the parent's available support system.
ANS: D
These are important data for the nurse to obtain. This question will provide information about the marital relationship (whether the parent speaks to the spouse), alternate support systems, and ability to communicate. By assessing these areas, the nurse can facilitate the identification and use of community resources as needed. It is an important part of assessment information to determine the parent's support network. The nurse is obtaining information to help support the parent through the diagnosis. The parent is not in need of additional parenting help at this time.
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The nurse is grading muscle strength during an assessment. The nurse should document strength of the arms as a 3 if:
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The procedure for examining the male breasts is essentially the same as that for the female breasts. The only modification is that the patient
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The nurse has gathered assessment data on a client admitted for suicidal tendencies. The nurse develops appropriate nursing diagnoses and formulates goals to achieve client outcomes. The nurse is utilizing which step of the nursing process?
1. Implementation 2. Evaluation 3. Planning 4. Assessment