A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?
Establishing the priorities of client care
Reinforcing teaching about the client's diagnosis
Asking the client about the presence of pain
Comparing the client's current laboratory values to previous results
The Correct Answer is B
A) Establishing the priorities of client care:
Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.
B) Reinforcing teaching about the client's diagnosis:
Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.
C) Asking the client about the presence of pain:
Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.
D) Comparing the client's current laboratory values to previous results:
Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.
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Related Questions
Correct Answer is D
Explanation
A) Administer liquids to the client using a syringe:
Administering liquids using a syringe may not address the underlying issue of food pocketing in the client's cheeks during meals. While syringe feeding may be necessary for clients with severe dysphagia, it does not address the need for comprehensive evaluation and intervention by a speech therapist.
B) Elevate the head of the client's bed to 45° during meals:
Elevating the head of the bed during meals is a standard intervention to help prevent aspiration in clients with dysphagia. While this intervention may be appropriate, it may not directly address the issue of food pocketing in the client's cheeks. Therefore, it is not the most comprehensive intervention for this specific problem.
C) Instruct the client to tilt their head back when swallowing:
Tilting the head back when swallowing is not a recommended intervention for clients with dysphagia. In fact, this maneuver can increase the risk of aspiration, as it can cause food or liquid to enter the airway. Therefore, this intervention would not be appropriate and could potentially exacerbate the client's swallowing difficulties.
D) Request a speech therapist consult from the provider:
This is the most appropriate intervention for addressing the client's dysphagia and food pocketing. Speech therapists are trained to assess and treat swallowing disorders, including pocketing of food in the cheeks. They can conduct a comprehensive evaluation of the client's swallowing function and develop individualized interventions to address the underlying causes of dysphagia. Therefore, requesting a speech therapist consult is the most effective way to manage this issue and improve the client's swallowing safety and efficiency.
Correct Answer is B
Explanation
A) Examine personal values:
While examining personal values is important in ethical decision-making, it is not the first step in addressing this particular ethical dilemma. Understanding personal values comes after gathering relevant facts and understanding the situation fully.
B) Collect the relevant facts:
This is the most appropriate initial step when facing an ethical dilemma. Gathering relevant information about the child's condition, the prescribed treatment, and the reasons for the parents' refusal is crucial for making informed decisions and developing a plan of action.
C) Create a plan of action:
Creating a plan of action is an important step in addressing the ethical dilemma, but it should come after collecting all relevant facts. Without a clear understanding of the situation, any plan of action may be incomplete or ineffective.
D) Agree on a desired outcome:
While determining a desired outcome is essential, it should be based on a thorough understanding of the situation, which comes from collecting relevant facts. Agreeing on an outcome before fully assessing the situation may lead to premature or uninformed decisions.
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