A client received baclofen to help with muscle spasticity. Four hours after administering the dose, the nurse assesses the client for decreased muscle spasms that cause pain and impair mobility. What phase of the nursing process does this represent?

Planning

Evaluation

Diagnosis

Implementation

Assessment

Answer and Explanation

The Correct Answer is B

A) Planning: The planning phase of the nursing process involves identifying specific goals and outcomes for the patient based on their condition. In this scenario, the nurse has already administered the medication and is assessing the effectiveness, which is a part of evaluating the plan of care. Planning would have occurred prior to medication administration to decide on interventions, but it is not the phase the nurse is in now.

B) Evaluation: Evaluation is the phase where the nurse assesses whether the nursing interventions and treatments are effective in achieving the desired outcomes. In this scenario, the nurse is evaluating the effect of the baclofen dose by observing whether it reduced muscle spasms and pain. The nurse's focus on assessing the result of the medication and its impact on the client’s condition indicates the evaluation phase of the nursing process.

C) Diagnosis: The diagnosis phase occurs before interventions and involves identifying health problems or conditions that need attention. In this case, a nursing diagnosis such as "impaired mobility" or "pain related to muscle spasticity" might have been formulated earlier, but the focus now is on evaluating the effectiveness of the treatment, not on diagnosing the problem.

D) Implementation: Implementation is the phase where the planned interventions are carried out. Administering baclofen to the client would fall under this phase. However, since the nurse is now assessing the effect of the medication after its administration, this action takes place after the intervention and falls under the evaluation phase, not implementation.

E) Assessment: Assessment is the phase where data is gathered about the patient’s condition, including physical and mental health. In this case, the nurse would have assessed the client initially to determine the need for baclofen, but four hours later, the nurse is evaluating the outcome of the medication, not gathering initial data. Therefore, the action described is not part of the assessment phase but rather the evaluation phase.

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Correct Answer is D

Explanation

A) Planning: The planning phase involves setting goals and determining the actions needed to achieve those goals. While the nurse may have planned to administer the medications through the nasogastric tube, the specific actions of crushing the tablets, mixing them with fluid, and administering them fall under a different phase. Therefore, planning is not the correct phase for the actions described.

B) Diagnosis: The diagnosis phase is when the nurse identifies and formulates nursing diagnoses based on data collected about the patient’s health status. The actions of preparing and administering medication do not fall under this phase, as diagnosis pertains to assessing health problems or needs.

C) Evaluation: Evaluation is the phase where the nurse assesses whether the goals or outcomes of the care plan have been met. The nurse would evaluate the effectiveness of the medication administration after it has been done, but the actual action of giving the medication is part of implementation, not evaluation.

D) Implementation: Implementation is the phase where the nurse carries out the planned interventions, including administering medications. In this case, the nurse is taking specific steps to prepare and administer the crushed tablets down the nasogastric tube, which is a direct action related to the care plan. This phase involves performing the tasks necessary to carry out the interventions that were decided during the
planning phase.

E) Assessment: Assessment involves collecting data about the client’s health status, such as physical examination, history, and vital signs. The actions taken to crush and administer medications are not part of the assessment phase, which focuses on gathering information, not delivering care.

A. Omeprazole and clarithromycin B. Ciprofloxacin and sucralfate C. Cimetidine and amoxicillin D. Tetracycline and metronidazole

Correct Answer is A

Explanation

A) Omeprazole and clarithromycin: Omeprazole is a proton pump inhibitor (PPI) that reduces stomach acid production, and clarithromycin is an antibiotic used to target Helicobacter pylori (H. pylori), the bacteria responsible for many peptic ulcers. In dual therapy for H. pylori eradication, omeprazole is used to create a less acidic environment, enhancing the effectiveness of antibiotics like clarithromycin. This combination is one of the most commonly used regimens in the treatment of peptic ulcer disease caused by H. pylori.

B) Ciprofloxacin and sucralfate: Ciprofloxacin is an antibiotic, and sucralfate is a medication used to coat the stomach lining to protect it from acid. While ciprofloxacin may be effective against certain bacterial infections, it is not typically used in dual therapy for H. pylori infections. Sucralfate is not an antibiotic and does not directly treat the bacterial cause of peptic ulcers, so this combination would not be ideal for H. pylori eradication.

C) Cimetidine and amoxicillin: Cimetidine is an H2-receptor antagonist used to reduce stomach acid production, and amoxicillin is an antibiotic that could potentially target H. pylori. However, this combination is less commonly used compared to PPI-based therapies. Cimetidine does not reduce acid as effectively as omeprazole (a PPI), making this combination less ideal for eradicating H. pylori.

D) Tetracycline and metronidazole: Both tetracycline and metronidazole are antibiotics used to treat infections, including H. pylori, but they are typically used in triple therapy regimens along with a PPI, not in dual therapy. While they can be effective in treating H. pylori, the combination of a PPI like omeprazole with clarithromycin remains the preferred choice for dual therapy.

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A client received baclofen to help with muscle spasticity. Four hours after administering the dose, the nurse assesses the client for decreased muscle spasms that cause pain and impair mobility. What phase of the nursing process does this represent?

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Correct Answer is D

Explanation

Which medications are most likely to be used in a dual drug therapy program for peptic ulcer disease from H. pylori?

Correct Answer is A

Explanation

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