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History taking: This refers to the process of gathering information about a patient's medical history, including their symptoms, past illnesses, medications, and family history. It involves asking questions and actively listening to the patient's responses.

Communication: Communication is a broad term that encompasses various aspects of interacting with a patient, including asking questions, active listening, providing explanations, and expressing empathy. Effective communication is crucial for building trust, understanding the patient's concerns, and delivering appropriate care.

Weighing of a patient: Weighing a patient is a specific measurement and is not a technique used for a physical examination. However, a patient's weight can be an essential piece of information in understanding their overall health and can be considered during the assessment process.

Pain:Explanation: Pain is a subjective experience because it is based on the patient's feelings and emotions. It varies from person to person and can't be precisely measured or observed by others. Patients often describe their pain based on personal sensations, making it subjective information.

Headache:Explanation: Like pain, a headache is a subjective symptom. Patients report their experience of a headache based on personal sensations, such as throbbing or pressure. It can't be directly measured or observed by healthcare providers; instead, it relies on the patient's description.

Lightheadedness:
Explanation: Lightheadedness is another subjective symptom. Patients may feel dizzy or unsteady, but this sensation can't be quantified objectively. It is based on the patient's perception of feeling lightheaded, making it subjective information.

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.

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.

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.

Adequate Fluid Intake:Explanation: Adequate fluid intake is essential for maintaining good health, but it is generally considered a short to medium-term goal. While ensuring a patient's proper hydration is crucial, it is typically resolved within a short timeframe by encouraging the patient to drink more fluids. Health professionals can monitor this relatively easily and make adjustments accordingly, making it a shorter-term goal compared to stroke rehabilitation.

Treatment of a Urinary Tract Infection (UTI):
Explanation: Treating a UTI is typically a short-term goal. Once diagnosed, UTIs can be effectively treated with antibiotics. Patients are usually prescribed a course of antibiotics, and symptoms generally improve within a few days. Monitoring the effectiveness of the treatment and ensuring the infection is completely resolved are parts of the short-term care plan.

Treatment of Pneumonia:Explanation: Similar to a UTI, treating pneumonia is usually a short to medium-term goal. Pneumonia often requires a course of antibiotics and supportive care. Patients can experience improvement within a few days to a couple of weeks, depending on the severity of the infection. Monitoring the patient's response to treatment and ensuring complete resolution are essential short to medium-term objectives in pneumonia management.

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.

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.

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.

Nursing Diagnosis: After assessing the patient, the nurse analyzes the data 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.

Planning: Based on the nursing diagnosis, the nurse develops a plan of care. This plan outlines the goals and outcomes the nurse hopes to achieve. It also includes interventions, which are the actions the nurse will take to address the nursing diagnoses.

Implementation: During this phase, the nurse puts the plan into action. This can include administering medications, providing treatments, educating patients, and other nursing interventions.

Maintaining skin integrity:Maintaining skin integrity is crucial for preventing pressure ulcers and other skin-related issues, especially for patients who are bedridden or have limited mobility. Preventive measures, like turning the patient regularly and keeping the skin clean and dry, are essential. While important, it is not always the highest priority and can be managed alongside other nursing interventions.

Adequate nutrition:Providing adequate nutrition is vital for the patient's overall health and recovery. Malnutrition can impair the healing process and weaken the immune system. However, in immediate critical situations, addressing the airway, breathing, and circulation (ABCs) takes precedence over nutritional concerns. Once the patient is stable, addressing nutrition becomes a priority in the nursing care plan.

Pain control:
Managing pain is crucial for a patient's comfort and well-being. Uncontrolled pain can cause anxiety, impair healing, and decrease the overall quality of life. Pain control is a high priority, but in certain emergencies where the patient's airway or circulation is compromised, managing pain might be temporarily secondary until the primary issues are addressed.

Psychosocial needs should be met first:Psychosocial needs are undoubtedly essential aspects of patient care. However, the priority of nursing problems depends on the patient's condition and the urgency of the situation. While psychosocial needs are critical, they might not always be the first priority, especially in acute or life-threatening situations. Safety and physiological needs often take precedence.

Problems don't need to be prioritized:In nursing practice, problems do need to be prioritized. Patients usually have multiple issues that need attention, and prioritization ensures that the most urgent or life-threatening problems are addressed first. Without prioritization, critical issues might be delayed, potentially leading to adverse outcomes.

Safety is the #1 priority:This statement is also correct. In nursing, patient safety is paramount. Ensuring the patient's safety is the top priority in all situations. This includes assessing and managing risks, preventing accidents or injuries, and providing a safe environment for both patients and healthcare providers. Safety concerns often take precedence over other nursing problems.

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.

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.

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

The nurse-to-nurse report:This statement is incorrect. Nurse-to-nurse report is essential for continuity of care, but it is not the basis for prioritizing patient problems. Prioritization is based on the patient's immediate needs and safety concerns.

Nonspecific data collection:
This statement is incorrect. Prioritization is based on specific data collected during the assessment, including physiological measurements, symptoms, and patient history. Nonspecific data collection wouldn't provide the necessary information for effective prioritization.

Managerial influence:This statement is incorrect. While managers might provide guidelines and policies, the direct care nurse at the bedside typically prioritizes patient problems based on clinical judgment, immediate needs, and the nursing process.

The doctor's responsibility:This statement is incorrect. While doctors order tests and procedures, it is the responsibility of the nursing staff to prepare the patient, provide necessary information, and ensure the patient's understanding and comfort before the procedure.

A dependent nursing action that requires the doctor's authorization:
This statement is incorrect. Preparing a patient for a diagnostic test and providing education about the procedure do not require direct authorization from the doctor. Nurses can perform these actions as part of their nursing practice.

An interdependent nursing action:This statement is incorrect. Interdependent nursing actions involve collaboration with other healthcare professionals. Educating the patient about a diagnostic test is primarily an independent nursing action, although collaboration with other team members might be necessary in certain cases.

Evaluation:Evaluation involves the assessment of a patient's response to nursing interventions and the effectiveness of the care plan. In this scenario, the nurse is not evaluating the patient's response to previous interventions but is rather in the process of conducting a new assessment.

Nursing Diagnosis:
Nursing diagnosis involves analyzing the data collected during the assessment to identify actual or potential health problems. The nurse has not reached the stage of formulating a nursing diagnosis in this scenario; she is still gathering data.

Implementation:Implementation is the phase of the nursing process where nursing interventions are carried out based on the nursing care plan. The nurse is not implementing interventions yet but is still in the process of data collection.

"Don't worry; this pain won't last forever."This statement dismisses the patient's concerns and does not encourage open communication about pain. It does not address the patient's current pain experience or provide a basis for effective pain management.

"You look pretty comfortable. Are you having any pain?"While this statement attempts to inquire about the patient's pain, it might not encourage the patient to open up about their pain experience. The patient might downplay their pain to appear strong or not to be a bother.

"Is this pain the same as the pain you had yesterday?"
This question is specific and might help in assessing the consistency and nature of the pain. However, it assumes the patient had pain yesterday and does not open the conversation effectively for the patient to express their pain experience freely.

Comprehensive plan to allow patient access to medical records.While electronic medical records (EMRs) do facilitate patient access to their medical information, the primary goal of the 2009 American Recovery and Reinvestment Act was broader. It aimed to improve healthcare quality, safety, and efficiency through the promotion of health IT, including EMRs.

Comprehensive document of health care costs.Although EMRs can include billing information, the main purpose of EMRs is to record clinical data for patient care and not specifically to document healthcare costs.

Comprehensive plan of care for all patients.
EMRs are tools used by healthcare providers to record patient information and manage healthcare delivery. While they can support the creation and management of care plans, their primary function is to store patient data electronically rather than generating care plans.

Make revisions in the plan as indicated by the shift report.Reviewing the nursing care plan before beginning care allows the nurse to integrate the information from the shift report into the plan. If there are necessary revisions based on the shift report, the nurse can make informed adjustments to the care plan.

Skip the shift report and begin with the initial assessment.Skipping the shift report is not advisable. Shift reports are crucial for continuity of care. The nurse needs to receive information about the patient's condition and ongoing care before starting the shift.

Begin nursing interventions without needing an initial assessment.
Starting interventions without an initial assessment can be unsafe and ineffective. Assessments provide the foundation for understanding the patient's current condition and planning appropriate care.

The nurse tells the patient not to worry about the surgery: This response dismisses the patient's concerns and does not engage in active listening. It does not encourage the patient to express their feelings or concerns.

The nurse assures the patient that the surgeon is very experienced: While this response provides information, it does not actively listen to the patient's concerns. It might be reassuring, but it doesn't engage in a deeper understanding of the patient's feelings.

The nurse shares her/his own experience of having surgery: Sharing personal experiences can sometimes be helpful, but in this context, it doesn't actively listen to the patient. It shifts the focus away from the patient's concerns to the nurse's experiences, which might not be relevant or helpful to the patient.

Closed Body Posture:Active listening often involves open body language, where the listener appears receptive and engaged. Closed body posture, where arms are crossed and body faces away, can indicate disinterest or disagreement, which is not a characteristic of active listening.

Three Senses - Sight, Hearing, and Touch:Active listening primarily involves the sense of hearing. While non-verbal cues like facial expressions and body language are important, active listening doesn't necessarily include touch or sight as direct senses employed during the process.

Only Verbal Messages:
Active listening involves not only hearing the words spoken but also understanding the emotions, intentions, and concerns behind those words. It includes interpreting verbal and non-verbal cues, making it more than just processing verbal messages.

Patient leaving against medical advice:When a patient decides to leave the hospital against medical advice, it's crucial to communicate this decision effectively. However, this situation does not specifically require a structured communication tool like SBAR. Rather, it necessitates clear communication to ensure the patient understands the risks and implications of leaving against medical advice.

Visitor fall:While a fall involving a visitor is an important incident, it doesn't typically require a structured communication tool like SBAR. Instead, it necessitates immediate response, assessment, and appropriate reporting within the hospital’s incident reporting system.

Needle stick injury to a nurse:
In the case of a needle stick injury, prompt reporting and proper follow-up are vital. While communication is crucial, it doesn't usually follow the structured format of SBAR. The nurse needs to report the incident to their supervisor or employee health, which would initiate appropriate protocols for testing, treatment, and documentation. Clear communication is necessary, but it doesn’t typically involve the use of the SBAR tool.