A client received baclofen to help with muscle spasticity. Four hours after administering the dose, the nurse assesses the client for decreased muscle spasms that cause pain and impair mobility. What phase of the nursing process does this represent?
Planning
Evaluation
Diagnosis
Implementation
Assessment
The Correct Answer is B
A) Planning: The planning phase of the nursing process involves identifying specific goals and outcomes for the patient based on their condition. In this scenario, the nurse has already administered the medication and is assessing the effectiveness, which is a part of evaluating the plan of care. Planning would have occurred prior to medication administration to decide on interventions, but it is not the phase the nurse is in now.
B) Evaluation: Evaluation is the phase where the nurse assesses whether the nursing interventions and treatments are effective in achieving the desired outcomes. In this scenario, the nurse is evaluating the effect of the baclofen dose by observing whether it reduced muscle spasms and pain. The nurse's focus on assessing the result of the medication and its impact on the client’s condition indicates the evaluation phase of the nursing process.
C) Diagnosis: The diagnosis phase occurs before interventions and involves identifying health problems or conditions that need attention. In this case, a nursing diagnosis such as "impaired mobility" or "pain related to muscle spasticity" might have been formulated earlier, but the focus now is on evaluating the effectiveness of the treatment, not on diagnosing the problem.
D) Implementation: Implementation is the phase where the planned interventions are carried out. Administering baclofen to the client would fall under this phase. However, since the nurse is now assessing the effect of the medication after its administration, this action takes place after the intervention and falls under the evaluation phase, not implementation.
E) Assessment: Assessment is the phase where data is gathered about the patient’s condition, including physical and mental health. In this case, the nurse would have assessed the client initially to determine the need for baclofen, but four hours later, the nurse is evaluating the outcome of the medication, not gathering initial data. Therefore, the action described is not part of the assessment phase but rather the evaluation phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["250"]
Explanation
Identify the total volume:
The client is ordered to receive 1000 mL of 0.9% saline.
Identify the infusion time:
The infusion time is 4 hours.
Set up the calculation:
We need to find out the IV pump rate in mL/hr. We can use the following formula:
(Total volume) / (Infusion time) = IV pump rate
4. Plug in the values and calculate:
(1000 mL) / (4 hours) = 250 mL/hr
Correct Answer is D
Explanation
A) "I will wash the inhaler once a week with running warm water.": This statement is accurate. It is important to wash the inhaler, especially the mouthpiece, at least once a week to prevent the build-up of medication residue and ensure proper function. The recommendation of using warm water is appropriate, and washing weekly is commonly advised by healthcare providers.
B) "I will administer the second puff 1 minute following the first puff.": This is correct. When using a metered-dose inhaler, it is recommended to wait about 1 minute between puffs to allow the medication to be inhaled properly and for the first dose to be fully delivered before administering the second dose. This ensures that each dose is effective.
C) "I will rinse my mouth with water or mouthwash after inhaler use.": This is a correct statement, particularly for inhaled corticosteroids. Rinsing the mouth after using an inhaler helps prevent the development of oral thrush and other side effects such as irritation or infection. It’s also a good habit to remove any leftover medication from the mouth.
D) "I will take slow deep breaths while activating the inhaler.": This statement indicates the need for additional education. The correct technique involves inhaling slowly and deeply after activating the inhaler, not while activating it. If the client exhales forcefully while pressing the inhaler, they may not be able to inhale the medication effectively. It is crucial that the client activates the inhaler and then takes a slow, deep breath to ensure the medication is delivered properly into the lungs.
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