When the nurse checks to see whether a patient is still having pain. 45 minutes after administering pain medication, the nurse is performing which part of the nursing process?
assessment
nursing diagnosis
evaluation
implementation
The Correct Answer is C
A. Assessment:
Explanation: Assessment is the first step in the nursing process. It involves gathering information about the patient's health status. This can include a patient's medical history, physical examination, and other vital signs. It's the phase where the nurse collects data to identify the patient's problems or needs.
B. Nursing Diagnosis:
Explanation: Nursing diagnosis is the second step in the nursing process, following assessment. During this step, the nurse analyzes the data collected during the assessment to identify nursing diagnoses or issues. Nursing diagnoses are clinical judgments about individual, family, or community responses to actual or potential health problems or life processes.
C. Evaluation:
Explanation: Evaluation is the last step in the nursing process. It involves assessing the patient's response to nursing interventions and determining if the goals and outcomes have been met. In the given scenario, the nurse is evaluating whether the pain medication administered 45 minutes ago has had the desired effect and has relieved the patient's pain.
D. Implementation:
Explanation: Implementation is the third step in the nursing process. During this phase, the nurse carries out the care plan that was designed during the planning phase. This can involve a variety of nursing actions, including administering medications, providing treatments, and educating patients. In the context of the scenario, giving pain medication is part of the implementation phase.
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Related Questions
Correct Answer is C
Explanation
A. Actions of the nurse are appropriate since his neighbor is his confidante, and the neighbor has assured him the information provided will not be shared.
Explanation: Even if the nurse's neighbor is considered a confidante, sharing specific patient information is still a breach of confidentiality. Healthcare professionals are obligated to follow strict guidelines regarding patient privacy, and sharing patient details with anyone outside the healthcare team, even if they promise not to share it further, is not ethically permissible.
B. The nurse is actively promoting nursing as a profession, and it is important to share information that might encourage others to pursue a nursing career.
Explanation: While it's positive for nurses to encourage others to pursue nursing, this should not involve sharing private patient information. There are many appropriate ways to promote the nursing profession, such as discussing the rewards of the job, the educational paths, or the impact nurses have on patient care. Patient confidentiality, however, should never be compromised in such attempts.
C. The nurse has violated the confidentiality of the patient by discussing personal information about the patient with his neighbor.
Explanation: This is the correct choice. As mentioned earlier, patient confidentiality is a fundamental ethical and legal principle in healthcare. Disclosing personal patient information to unauthorized individuals, even if unintentional or with good intentions, is a violation of this principle.
D. The nurse has not violated the confidentiality of the patient because the patient is terminal: sharing this information will not harm the patient.
Explanation: A patient being terminal does not change the rules of confidentiality. Regardless of a patient's condition, their right to privacy remains intact. Sharing information about a patient's terminal status without proper authorization is still a breach of confidentiality and is not considered ethical practice.
Correct Answer is B
Explanation
A. North American Nursing Diagnosis Association (NANDA) revises the diagnostic labels every 5 years:
This statement is not accurate. The North American Nursing Diagnosis Association (NANDA) International does review and revise the nursing diagnoses regularly, but it's not on a fixed 5-year schedule. Changes are made based on evolving healthcare practices, new research, and emerging health issues.
B. A nursing diagnosis describes a health problem amenable to intervention:
This statement is true. A nursing diagnosis identifies a specific health problem that can be addressed through nursing interventions. It provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.
C. Medical diagnosis is included in the nursing diagnosis:
This statement is incorrect. Nursing diagnoses are distinct from medical diagnoses. Medical diagnoses identify diseases or pathologies, whereas nursing diagnoses focus on the patient's responses to the health condition. Nursing diagnoses are within the domain of nursing practice and are formulated based on nursing assessments.
D. LPNs/LVNs formulate nursing diagnoses:
This statement is generally true. Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) can formulate nursing diagnoses as part of their scope of practice. However, the complexity of the diagnosis and the depth of assessment often determine the level of nurse involved in formulating nursing diagnoses. Registered Nurses (RNs) typically handle more complex patient cases and nursing diagnoses
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