The nurse has carried out interventions that were identified as part of the plan of care. As part of evaluating care, the nurse would focus on determining whether:
1. every intervention was actually carried out.
2. desirable or undesirable client responses are present.
3. other nurses know which nursing interventions were carried out.
4. the client understood the rationale for all interventions.
ANS: 2
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An older client with diabetes mellitus has received a thorough medical examination and is cleared to begin a walking program. The nurse working with the client recommends that the client
A) wear shoes with thick inflexible soles. B) include a warm-up period at the beginning and a cool-down period at the end with a slower pace. C) continue walking if she becomes short of breath because this will strengthen the heart and build resilience. D) carry extra insulin in case she begins to feel weak while walking.
A new mother asks the nurse when the "soft spot" on her son's head will go away. The nurse's answer is based on the knowledge that the anterior fontanel closes after birth by:
a. 2 months. b. 8 months. c. 12 months. d. 18 months.
The nurse is assessing the effectiveness of fluid replacement therapy in a patient who has a fluid volume deficit. Which assessment findings would indicate the therapy is effective?
1. Blood pressure 90/48 mm Hg 2. Weight gain of 2 pounds since yesterday 3. Urine output increase to 40 mL per hour 4. Tenting of skin 5. Serum osmolality of 284 mOm/kg
A client has been severely depressed and suicidal. After admission to an inpatient psychiatric unit, antidepressant medication is administered
As the client becomes more energized and communicative, what should be the priority nursing intervention for this client? A) Allowing the client to have unsupervised passes to his or her home B) Encouraging the client to participate in group activities C) Increasing the vigilance regarding the client's suicidal precautions D) Recognizing that the client's suicidal potential has decreased