The nurse is checking the client’s blood sugar before administering insulin to a diabetic client. Which part of the nursing process is being fulfilled?
Evaluation.
Assessment.
Planning.
Implementation.
The Correct Answer is B
Choice A rationale
Evaluation is the phase of the nursing process where the nurse assesses the effectiveness of the interventions and determines whether the patient’s goals have been met. Checking blood sugar before administering insulin is not part of the evaluation phase.
Choice B rationale
Assessment is the phase of the nursing process where the nurse gathers information about the patient’s condition. Checking the client’s blood sugar before administering insulin is an assessment activity, as it involves collecting data to determine the patient’s current blood glucose level.
Choice C rationale
Planning is the phase of the nursing process where the nurse develops a plan of care based on the assessment data. Checking blood sugar is not part of the planning phase; it is an assessment activity.
Choice D rationale
Implementation is the phase of the nursing process where the nurse carries out the interventions outlined in the plan of care. While administering insulin is part of the implementation phase, checking blood sugar is an assessment activity that occurs before the implementation of the intervention.
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Correct Answer is D
Explanation
Choice A rationale
Correcting the physician’s orders to match the chart is not within the nurse’s scope of practice. Nurses should not alter physician orders.
Choice B rationale
Ignoring the discrepancy is not appropriate. Nurses have a responsibility to ensure patient safety and accurate documentation.
Choice C rationale
Documenting the discrepancy but taking no further action does not address the potential risk to patient safety. Further action is necessary.
Choice D rationale
Documenting the discrepancy and notifying the physician is the correct course of action. This ensures that the physician is aware of the issue and can make any necessary corrections.
Correct Answer is A
Explanation
Choice A rationale
Facial expressions are indeed an example of non-verbal communication. Non-verbal communication includes body language, facial expressions, gestures, and eye contact. These cues can provide significant insights into a client’s feelings and attitudes.
Choice B rationale
Verbal communication is not always an accurate reflection of what the client really feels. Clients may sometimes say what they think the nurse wants to hear or may not fully express their true feelings verbally.
Choice C rationale
Nonverbal communication often reflects what the client is truly feeling more accurately than verbal communication. For example, a client may say they are not in pain, but their body language, such as grimacing or guarding a body part, may indicate otherwise.
Choice D rational
Body posture is an example of non-verbal communication, not verbal communication. Verbal communication involves spoken or written words, while non-verbal communication includes body language, facial expressions, and other physical cues.
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