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 D
Explanation
In a Mental Status Examination (MSE), thinking/content of thought is one of the key areas assessed. It refers to the content and process of a person's thoughts. The examiner will evaluate whether the person's thinking is coherent, organized, and logical, or if it is fragmented, disorganized, or delusional. They will also look for evidence of hallucinations, obsessions, or compulsions.
Speech and ability to communicate (a) are also assessed in the MSE, but they focus more on how the person expresses themselves, rather than the content of their thoughts. Judgment (b) refers to a person's ability to make decisions and solve problems, and memory (c) is the ability to recall past events and information. While both areas are important to assess in a mental health evaluation, they do not specifically focus on what the person is thinking.
Correct Answer is ["4"]
Explanation
The nurse will administer 4 capsules. Since the order reads Lithium 600 mg and the nurse has 150 mg capsules on hand, the nurse will need to administer 600 mg / (150 mg/capsule) = 4 capsules to fulfill the order.
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