The LPN/LVN selects nursing interventions to continue during which stage of the nursing process?
1. Assessment
2. Diagnosis
3. Intervention
4. Evaluation
5.
4
Rationale 1: Nursing interventions are not selected during assessment; data collection occurs.
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A patient is admitted to the critical care unit (CCU) with a diagnosis of cardiomyopathy. When reviewing the patient's most recent laboratory results, the nurse should prioritize assessment of which of the following?
A) Sodium B) AST, ALT, and bilirubin C) White blood cell differential D) BUN
A nurse needs to auscultate a patient's lung sounds. The nurse should place the patient in what position?
a. Sims' b. Prone c. Sitting d. Lithotomy
A nurse working in a walk-in clinic is approached by a person with a history of violent behavior. The person states, "I want to go to the hospital for a rest. You better get me in or I'll do something bad. I can get a gun."
An appropriate response from the nurse would be: a. "If I get you admitted, will you promise to behave yourself?" b. "You seem very anxious to be hospitalized. What do you think will happen if you aren't hospitalized?" c. "Do you have a gun? I'm not sure I believe you. Are you really threatening to kill yourself or someone else?" d. "Do you really want to go to the hospital? Would you be satisfied if I were able to find you someplace safe to rest?"
A rape victim tells the nurse, "I should not have been out on the street alone." Which is the nurse's most therapeutic response?
a. "Rape can happen anywhere." b. "Blaming yourself only increases your anxiety and discomfort." c. "You believe this would not have happened if you had not been alone?" d. "You are right. You should not have been alone on the street at night."