Chapter 2: The Nursing Process

After the nursing plan of care has been developed, the nurse knows that:

each encounter with the client is an opportunity to reassess and revise the plan of care if necessary.

The expected outcome for a client with a new diagnosis of diabetes mellitus is: "client will describe appropriate actions when implementing the prescribed medication routine." Which statement by the client indicates the outcome expectation has been met?

"I will test my glucose level before meals and use sliding scale insulin."

A student is reviewing a client's chart before giving care. She notes the following diagnoses in the contents of the chart: "appendicitis" and "acute pain." Which of the diagnoses is a medical diagnosis?

Appendicitis

The assessment phase of the nursing process has to be well organized to prevent omission of pertinent information. What is an advantage of using the functional health framework?

Client strengths and assets can be identified.

The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client is breathing easier. The nurse is engaging in which phase of the nursing process?

Evaluating

A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. Which type of assessment would the nurse perform?

Focused assessment

Which action is taken during the maintenance phase of an interview? Select all that apply

Keep focused on the task or goals to ensure that needed data are obtained and goals are achieved. Observe the client's behavior, and listen attentively

The nurse is caring for Mr. H., a 35-year-old man who is hospitalized following a motorcycle accident. He has a traumatic brain injury. The nurse is working with Mr. H. on self-care behaviors. The following would help the nurse to assess the success of the nursing interventions except which of the following?

Model self-care behaviors for the client.

A client recovering after an appendectomy is reporting pain. The nurse administers the ordered pain medication and assists the client to splint the incision. What is the nurse's next step in implementing the plan of care?

Reassess the client to determine the effectiveness of the interventions.

A client describes pain in the right leg as aching at 8/10 on a pain scale. What type of cue is a client's description of pain in the right leg.

Subjective

The client has a diagnosis of Risk for Injury related to falls. How would the nurse know if the intervention was successful?

The client is free of falls.

The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89%. The nurse raises the head of the bed and applies oxygen at 3L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Mark all that apply.

The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases

The nurse is preparing a client for surgery when the client tells the nurse that he no longer wants to have the surgery. How should the nurse most appropriately respond?

Discuss with the client the reasons for declining surgery.

A nurse manager notes an increase in the frequency of client falls during the last month. To promote a positive working environment, how would the nurse manager most effectively deal with this problem?

Investigate the circumstances that contributed to client falls.

Which of the following is an example of a time-lapse reassessment?

Natalia is a visiting nurse who has an appointment with Donald, an 85-year-old man with mobility issues. Natalia has worked with Donald in the past on the ways in which he can prevent falls. Today she wants to assess how he is doing with the fall prevention strategies they practiced before.

The nurse is caring for a 10-year-old client who is newly diagnosed with a seizure disorder. What variable would alter the nurse's plan for educating the client and parent?

The client has a 12-year-old sister who has been treated for a seizure disorder for 3 years