Which nursing documentation demonstrates the integration of patient-centered care?
Steady gait observed when ambulating.
Social worker paged for consultation.
Nursing literature reviewed for best practice approaches.
Discussed dietary preferences with client.
The Correct Answer is D
Patient-centered care involves actively involving the patient in their care and considering their preferences, values, and goals. By discussing dietary preferences with the client, the nurse is demonstrating a patient-centered approach. This documentation indicates that the nurse took the time to engage in a conversation with the client to understand their dietary preferences,
which can help tailor the care plan to meet the client's individual needs and preferences. "Steady gait observed when ambulating" focuses on the nurse's observation and assessment but does not specifically involve the patient's preferences or goals.
"Social worker paged for consultation" indicates collaboration with another healthcare professional but does not necessarily reflect the patient's active involvement or preferences. "Nursing literature reviewed for best practice approaches" highlights evidence-based practice but does not directly involve the patient's preferences or engagement in decision-making.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Pancytopenia refers to a decrease in all three major blood cell types: red blood cells (anemia), white blood cells (leukopenia), and platelets (thrombocytopenia). It is a potentially serious side effect that can lead to increased susceptibility to infections, anemia-related symptoms (fatigue, weakness), and an increased risk of bleeding. Prompt reporting is necessary for further
evaluation and appropriate management.
While melena (dark, tarry stools) is a concerning side effect, it typically indicates gastrointestinal bleeding, which should also be reported promptly but may not require immediate action unless the bleeding is severe or accompanied by other symptoms.
Decreased vision can be a side effect of certain medications, including NSAIDs, but it does not usually require immediate reporting unless it is severe or rapidly progressive. Hyperglycemia (high blood sugar) can occur with NSAID therapy, especially in individuals with preexisting diabetes or impaired glucose tolerance. While it should be monitored and managed appropriately, it does not typically require immediate reporting unless it is extremely high or associated with other concerning symptoms.
Correct Answer is C
Explanation
Loop diuretics, such as furosemide, are known to promote diuresis (increased urine output) and can cause electrolyte imbalances, including low potassium (hypokalemia). The patient's statement about eating a diet rich in potassium-containing foods like potatoes, bananas, avocadoes, strawberries, and spinach is incorrect in this context. These foods are indeed good sources of potassium, but when taking loop diuretics, it is necessary to monitor and potentially restrict potassium intake to prevent excessive potassium levels.
"I will weigh myself daily and report to my physician if I gain more than 3 lbs in 1 day." This statement reflects the patient's understanding of the need to monitor their weight daily as a means of assessing fluid balance. Rapid weight gain may indicate fluid retention, which should be reported to the physician.
"This medication can cause dehydration, so I will stay hydrated by consuming at least 2 L or more of fluid per day." This statement demonstrates awareness of the potential for dehydration when taking loop diuretics and the importance of staying adequately hydrated by consuming an appropriate amount of fluids.
"I will change position slowly because I can become dizzy easily while taking this medication." This statement reflects the understanding that loop diuretics can cause orthostatic hypotension,
leading to dizziness upon sudden changes in position. Taking precautions and changing position slowly can help prevent falls and related injuries.
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