When the nurse identifies a health problem or alteration in a client's health status that requires a nursing intervention, the nurse is performing which step of the nursing process?
a. Diagnosis
b. Planning
c. Intervention
d. Evaluation
ANS: A
The nursing diagnosis consists of three parts: (1) problem, (2) etiology, and (3) evidence. The problem is a statement identifying a health problem or alteration in a client's health status requiring nursing intervention. Planning occurs after problem identification. Interventions occur during implementation. The effectiveness of the interventions is evaluated in the evaluation phase.
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A client, aged 16 years, comes to the crisis clinic. The nurse learns she is being molested by her
uncle. She has told her mother, who thinks she is lying. In a disjointed fashion, the client tells the nurse the following: (1) "I am all confused. I got desperate and tried to kill myself.". (2) "For a few days I just sat in my room. I told my mother I was sick.". (3) "I tried to figure out what to do. First I thought I would live with my friend, but her mother said I couldn't. Then I thought I would go live in a homeless shelter.". (4) "I told my mother, hoping she would tell my uncle he couldn't come to the house anymore.". The client has actually described the four distinct phases of crisis according to Caplan. Which of the following reflects the statements in the correct order to coincide with Caplan's theory? a. 1, 2, 3, 4 b. 4, 2, 3, 1 c. 3, 2, 1, 4 d. 4, 3, 2, 1
The service requested and needed by an applicant to home health that would not be eligible for coverage under Medicare is
a. home health aide. b. housekeeping services. c. physical therapy. d. speech therapy.
A patient is diagnosed with diabetic ketoacidosis. The nurse realizes that the mechanism with which the patient has been receiving energy is through which of the following?
1. aerobic metabolism 2. extraction 3. anaerobic metabolism 4. affinity
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?
a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation.