A resident in a nursing home complains of constipation. The nurse checks the patient record and notes that he has not had a bowel movement in three days. She/he then performs a digital rectal exam and feels hard stool. Which part of the nursing process is this?
evaluation
assessment
nursing diagnosis
implementation
The Correct Answer is B
A. Evaluation:
Evaluation involves the assessment of a patient's response to nursing interventions and the effectiveness of the care plan. In this scenario, the nurse is not evaluating the patient's response to previous interventions but is rather in the process of conducting a new assessment.
B. Assessment:
This statement is correct. The nurse is in the assessment phase of the nursing process. She is collecting data by checking the patient's record, performing a physical examination (digital rectal exam), and noting the patient's complaint and signs of constipation (no bowel movement for three days, hard stool). Assessment is the first step of the nursing process and involves data collection to identify health problems and needs.
C. Nursing Diagnosis:
Nursing diagnosis involves analyzing the data collected during the assessment to identify actual or potential health problems. The nurse has not reached the stage of formulating a nursing diagnosis in this scenario; she is still gathering data.
D. Implementation:
Implementation is the phase of the nursing process where nursing interventions are carried out based on the nursing care plan. The nurse is not implementing interventions yet but is still in the process of data collection.
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Related Questions
Correct Answer is ["4"]
Explanation
To calculate the number of 40mg capsules needed for a 2-grain dose, you need to convert grains to milligrams since the supply is given in milligrams (mg).
1 grain is approximately equal to 64.8 milligrams.
Now, let's calculate:
2 grains * 64.8 mg/grain = 129.6 mg
So, the nurse would give 129.6 milligrams of the medication. Since the supply is in 40mg capsules, you'll need to divide the total dose by the amount in each capsule to determine the number of capsules needed:
129.6 mg / 40 mg/capsule ≈ 3.24
Since you can't give a fraction of a capsule, the nurse would give 4 capsules to achieve a dose of approximately 129.6 milligrams.
Correct Answer is B
Explanation
A. Summarizing: Summarizing involves condensing the patient's words into a concise form. It's a useful technique when the nurse wants to review and confirm what the patient has said, ensuring understanding and demonstrating active listening.
B. General lead: A general lead is an open-ended statement or question that allows patients to express themselves without feeling restricted. For example, "Tell me how your night was?" is a general lead because it prompts the patient to share their experiences openly.
C. Offering of self: Offering of self involves making oneself available, both physically and emotionally, to the patient. This can include showing empathy, understanding, and a willingness to listen. It helps create a therapeutic nurse-patient relationship.
D. Clarifying: Clarifying is a technique used when the nurse needs more specific information. It involves asking questions to ensure that the nurse correctly understands the patient's message, avoiding misunderstandings and ensuring clear communication. For instance, the nurse might say, "Can you please explain that part again?" to clarify a confusing statement made by the patient.
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