A hospital's nursing assessment form reflects first-level and second-level assessment. From this information, the nurse seeking employment at this facility determines that nursing service follows which theorist?
1. Orem
2. Roy
3. Benner
4. Leininger
Correct Answer: 2
Roy's Adaptation Model states that assessment involves two levels. First-level assessment includes collecting data about output behaviors related to the four adaptive modes. Second-level assessment includes collecting data about internal and external stimuli that are influencing the identified behaviors. The other theories and models listed do not direct that assessment involves two levels.
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A patient is receiving discharge instructions and shares with the nurse that he intends to do a lot of traveling. What instruction should the nurse include?
a. "Pack plenty of extra colostomy supplies in your checked airline luggage. Some places you might visit do not always carry the supplies you will need." b. "Exercise caution with new foods, espe-cially local fruits and vegetables because they may cause diarrhea or gas." c. "If visiting somewhere where drinking local water is not advised, irrigating the colostomy with the local water is still okay." d. "Repeat back to me what we just talked about so that you will remember every-thing you have been taught."
The nurse evaluating the laboratory studies of a 46-year-old client would recognize that the laboratory report most suggestive of the presence of diabetes mellitus is
a. a glucose tolerance test that takes 2 hours to return to normal. b. fasting blood glucose level of 151 mg/dl. c. high urine ketone levels with +2 glycosuria. d. random ("casual") blood glucose level of 80 mg.
A patient, on day seven of treatment for a traumatic brain injury, begins to demonstrate large amounts of urine output and an elevated serum sodium level. Which of the following does this assessment finding suggest to the nurse?
1. syndrome of inappropriate antidiuretic hormone 2. cerebral salt wasting 3. diabetes insipidus 4. renal failure
Ten minutes after the nursing assistant applies an Aquathermia pad to the client's extremity, the client states that the pad is not warm. Which should the nurse implement?
1. Tell the nursing assistant to secure pad to client tightly. 2. Instruct assistant to increase temperature control on pad. 3. Assess the client's condition and pad for proper function. 4. Discontinue treatment because the client is not tolerating it.