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
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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Related Questions
Correct Answer is C
Explanation
Explanation:
A. Increased bowel sounds:
In end-of-life care, clients often experience a decrease in bowel sounds rather than an increase. Bowel sounds may diminish or become absent as the body's systems slow down.
B. Hypertension:
Hypertension is less commonly observed in clients at the end of life. Instead, blood pressure may decrease as the body's overall function declines.
C. Mottled skin:
Mottled skin, characterized by a blotchy or marbled appearance, is a common finding in clients approaching the end of life. It occurs due to changes in peripheral circulation and may indicate decreased perfusion.
D. Moist mucous membranes:
In contrast to moist mucous membranes, clients at the end of life may experience dry mucous membranes. Reduced oral intake and hydration levels can lead to dryness of the mouth and mucous membranes.
Correct Answer is ["B","C","D","E"]
Explanation
A. Grab bars are installed in the bathroom:
Correct placement of grab bars in the bathroom can enhance safety for individuals who have mobility challenges, such as those who have experienced a stroke. This is not a safety hazard but rather a safety measure.
B. Medications are stored in a clear bag:
Storing medications in a clear bag may increase the risk of accidental misuse or confusion, particularly for a stroke client who may have cognitive or visual impairments.
C. Area rugs are placed in the living room:
Area rugs can be a safety hazard, especially for individuals with mobility issues or those at risk of falls. Rugs can cause tripping hazards if they are not properly secured or if there are wrinkles or uneven surfaces.
D. Dim lighting installed throughout the house:
Dim lighting can contribute to safety hazards, particularly for individuals with visual impairments or mobility challenges. Insufficient lighting increases the risk of falls and accidents, especially in areas such as staircases, hallways, and bathrooms.
E. The hot water heater is set at 54°C (130° F):
Water temperature set at 54°C (130° F) is excessively hot and poses a scalding hazard, especially for individuals with sensory impairments or reduced ability to perceive temperature changes. Lowering the water heater temperature to a safer range is recommended to prevent scalding injuries.
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