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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Problems that cause severe discomfort to the client: While addressing discomfort is important in providing holistic care, it is not the highest priority in nursing. The nurse’s primary focus should be on life-threatening issues or those that could deteriorate the client’s condition rapidly. Severe discomfort can be managed once immediate threats to life are addressed.
B) Problems the client deems most important: Although it’s essential to consider the client’s perspective and involve them in their care plan, problems that are most important to the client may not always be the most urgent or life-threatening. For example, the client may prioritize pain management, but addressing life-threatening issues must always take precedence.
C) Problems that are immediately life-threatening for the client: This is the correct answer. According to Maslow’s hierarchy of needs and the nursing prioritization framework, life-threatening problems should always be the nurse's first priority. These are issues that, if not addressed immediately, can lead to death or severe complications. For instance, airway obstruction, severe bleeding, or shock would require immediate intervention.
D) Problems that are identified as priority by the physician: While the physician’s orders and priorities should be taken into consideration, the nurse must independently assess and prioritize care based on the overall health status of the client. This includes using clinical judgment to identify life-threatening conditions, even if they are not explicitly stated in the physician’s orders. Nurses are trained to identify priority issues through their assessments and are responsible for making decisions that ensure the client’s safety.
Correct Answer is B
Explanation
A) Cut the 50 mcg/hr patch in half to obtain 25 mcg/hr dosing: Cutting a fentanyl patch in half is not recommended because it can lead to inconsistent dosing. The patches are designed to release medication at a controlled rate, and cutting them could cause the medication to be released too quickly or unevenly, which could result in overdose or insufficient relief of pain. It’s essential to follow the manufacturer's guidelines and avoid altering the patch.
B) Ask pharmacy to send a 25 mcg/hr transdermal patch: The best course of action is to ask the pharmacy to send the correct 25 mcg/hr transdermal patch. This ensures that the patient receives the prescribed dose in the most accurate and safe manner. The 25 mcg/hr patch is formulated to deliver the correct amount of medication, and it will avoid any risk associated with altering the patch.
C) Contact the healthcare provider and request to increase the dose to 50 mcg/hr: Requesting an increase in the dose is premature without a clear justification from the healthcare provider. The healthcare provider decreased the dose to 25 mcg/hr for a reason, possibly due to side effects, effectiveness, or other clinical factors. Altering the prescribed dose without a proper review would be inappropriate. The nurse should follow the current prescribed dose and resolve the issue by requesting the correct patch from the pharmacy.
D) Remove the previous patch and apply the 50 mcg/hr patch in a different location: Switching to the 50 mcg/hr patch without approval could lead to administering an incorrect dose of fentanyl, which can increase the risk of overdose or severe side effects like respiratory depression. The nurse should adhere to the prescribed 25 mcg/hr dose and request the correct patch from the pharmacy rather than substituting with a higher dose patch.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.