A nurse enters a client's room to evaluate the response to IV pain medication administered by request 20 minutes earlier
The nurse finds the client in the same position as when the medication was administered. The client states, "I do not want to move." The nurse asks the client to rate the current level of pain. Which aspects of the nursing process do these action represent?
Select all that apply.
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
E) Evaluation
Answer: A, D, E
The nurse is engaging simultaneously in an assessment, implementation, and evaluation as she (1) observes the client's behavior and asks about her current pain level (assessment), (2) implements an aspect of care by following up on the prior pain administration (implementation), and (3) evaluates the client's response to the earlier pain administration (evaluation). Phases of the nursing process overlap and are not separate entities.
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When a client refers to his or cultural perception or identity that has been passed from one generation to the next, the nurse understands that this is an example of:
a. culture c. heritage b. ethnicity d. race
Which of the following are strengths that older people have which are advantages that many younger adults do not? (Select all that apply.)
A) They probably have had more experience with coping, problem solving, and managing crises because they have lived longer. B) Most older persons do not have concerns about what they are going to be when they "grow up" because they have already grown up. C) Most elderly people have not learned who they really are. D) They have faced and overcome numerous stresses.
As a student nurse utilizing Roy's model in practice, your nursing interventions will focus on which of the following?
a. supplementation of self-care requisites b. manipulation of stimuli to foster successful adaptation c. promotion of symphonic interaction between human and environmental fields d. use of true presence to facilitate the becoming of the participant e. therapeutic, interpersonal process between the nurse and the patient
A patient is admitted to the hospital with severe renal colic. The nurse's first priority in management of the patient is to
a. administer opioids as prescribed. b. obtain supplies for straining all urine c. encourage fluid intake of 3-4L/day d. keep the patient NPO in preparation for surgery