You find a patient on the floor at shift change. She is awake and alert. She is confused now and was not controlled before being found on the floor.
What is your first step in the nursing process in this situation?
Leave the patient to get help.
Call the patient’s health-care provider from your cell phone.
Help the patient get up and then document your findings in the chart.
Gather more information by making observations about the patient.
The Correct Answer is D
The first step in the nursing process is assessment, which involves gathering information about the patient’s condition. In this situation, the nurse should make observations about the patient’s physical and mental status, including any signs of injury or distress. This information can then be used to determine the appropriate course of action and provide appropriate care. The other
The other options do not represent the first step in the nursing process and may not be appropriate in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Involuntary admission to a psychiatric facility, also known as involuntary commitment, is a legal process in which a person is admitted to a psychiatric hospital without their consent. The criteria for involuntary admission may vary depending on the jurisdiction, but generally include a determination that the person is a danger to themselves or others or is unable to care for themselves due to a mental illness.
Therefore,
Options b, c, and d are all valid reasons for involuntary admission, as they relate to the person's ability to cause harm to themselves or others or their inability to care for themselves.
Options a and e, on the other hand, are not valid reasons for involuntary admission as they do not relate to the person's mental state or potential for harm to themselves or others.
Correct Answer is A
Explanation
This statement by the student nurse demonstrates the technique of stating the implied and seeing the client's behavior. The student nurse has observed the client pacing the halls and having a tense look on their face, which implies that the client may be feeling anxious. By stating this observation to the client, the student nurse is validating the client's experience and opening a dialogue about their feelings. This technique can help the client feel heard and understood and can facilitate a therapeutic relationship between the client and the nurse.
Option B is an open-ended question that can encourage the client to share more about their feelings, but it does not demonstrate the technique of stating the implied and making an observation about the client's behavior.
Option C is a statement that may be perceived as judgmental or confrontational and does not demonstrate the technique of stating the implied and making an observation about the client's behavior.
Option D is a statement that is focused on the nurse's agenda rather than the client's needs and does not demonstrate the technique of stating the implied and seeing the client's behavior.
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