A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?

Data collection

Evaluation

Planning

Implementation

Answer and Explanation

The Correct Answer is C

Explanation:

A. Data collection:

Data collection is the initial step of the nursing process where the nurse gathers information about the client's health status, including physical, psychological, social, and environmental factors. This involves conducting assessments, obtaining medical histories, performing physical exams, reviewing diagnostic tests, and gathering information from the client, family members, and other healthcare providers. In the scenario, data collection would involve gathering information about the client's postoperative condition, recovery progress, functional abilities, support system, home environment, and any other relevant factors that would influence the discharge planning process.

B. Evaluation:

Evaluation is the step of the nursing process where the nurse assesses the client's response to interventions, measures progress toward goals, and determines the effectiveness of the care provided. It involves comparing the client's actual outcomes with expected outcomes, identifying any deviations or areas needing improvement, and making adjustments to the care plan as necessary. In the scenario, evaluation would occur after the implementation of the discharge plan to assess the client's readiness for discharge, the achievement of goals, and the overall success of the interventions implemented.

C. Planning:

Planning is the phase of the nursing process where the nurse, in collaboration with the client, family, and healthcare team members, develops a comprehensive plan of care based on the collected data and identified needs. This includes setting priorities, establishing expected outcomes and goals, determining appropriate interventions, creating a timeline for implementation, and coordinating resources and services. In the scenario, planning involves working with the social worker and physical therapist to develop a discharge plan that addresses the client's postoperative needs, ensures continuity of care, promotes recovery, and supports a smooth transition from the healthcare facility to the home or next level of care.

D. Implementation:

Implementation is the phase of the nursing process where the nurse carries out the interventions outlined in the care plan. This involves putting the plan into action, providing direct care, educating the client and family, coordinating services, monitoring progress, and advocating for the client's needs. In the scenario, implementation would occur as the nurse, along with the social worker and physical therapist, initiates the discharge plan, arranges for services and resources, provides education and instructions to the client and family, and ensures that all necessary preparations are made for the client's transition from the hospital.

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Correct Answer is B

Explanation

Explanation:

A. Glasgow coma scale result - This would be included in the assessment segment of SBAR, as it provides a clinical evaluation of the client's current neurological status.

B. History of the injury - The situation segment is used to briefly explain the current situation or the reason for the report. Including the history of the injury provides context about why the client is receiving care.

C. Medication during the next shift - This information is part of the Recommendation segment of SBAR. The nurse should include any upcoming medication administration, changes in medication orders, or specific medications that need to be administered during the next shift.

D. Intracranial pressure readings - This information should be included in the Assessment segment of SBAR. It provides important data about the client's intracranial status, helps monitor for changes or trends, and guides ongoing management and interventions.

A. Battery B. Assault C. Abuse D. Malpractice

Correct Answer is D

Explanation

Explanation:

A. Battery: Battery refers to intentional harmful or offensive touching without consent. In the context of healthcare, it usually involves physical contact or procedures performed without the patient's consent. An inadvertent medication error, even if it causes harm, does not typically constitute battery unless there was an intentional act of administering the wrong medication against the patient's will.

B. Assault: Assault is the threat of harmful or offensive contact. It involves creating a reasonable apprehension of imminent harmful or offensive contact in the patient's mind. An inadvertent medication error, while it may cause harm, does not typically constitute assault unless there was an intentional threat of harm made to the patient.

C. Abuse: Abuse involves the intentional mistreatment or harm of another person. An inadvertent medication error is not considered abuse unless there was an intentional act to harm the patient.

D. Malpractice: Malpractice refers to professional negligence or failure to provide the standard of care expected in a particular profession, such as nursing. In the scenario described, the inadvertent medication error resulting in a severe allergic reaction and prolonging the client's hospitalization could be considered a case of malpractice. The nurse failed to meet the standard of care expected in administering medications safely, leading to harm to the patient.

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A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

Correct Answer is B

Explanation

A nurse's inadvertent medication error results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

Correct Answer is D

Explanation

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