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 ["12"]
Explanation
1. Convert the child's weight from pounds to kilograms:
There are approximately 2.2 pounds in 1 kilogram.
33 pounds / 2.2 pounds/kg = 15 kg (approximately)
2. Calculate the total milligrams of amoxicillin needed per dose:
The order is for 20 mg/kg/dose.
The child weighs 15 kg.
20 mg/kg * 15 kg = 300 mg
3. Determine the concentration of the amoxicillin suspension:
The label shows the concentration is 125 mg/5 mL.
4. Set up a proportion to find the volume (in mL) needed:
125 mg / 5 mL = 300 mg / x mL
5. Solve for x:
Cross-multiply: 125x = 300 * 5
125x = 1500
x = 1500 / 125
x = 12 mL
Answer: You will administer 12 mL per dose.
Correct Answer is C
Explanation
A) Use perfumes and air fresheners: Using perfumes and air fresheners may actually worsen nausea for some clients, as strong scents can trigger or exacerbate feelings of nausea, particularly in individuals undergoing chemotherapy. It is generally advisable to avoid strong odors in the environment to prevent triggering nausea.
B) Eat foods that are high in fibre: While a balanced diet is important, high-fibre foods may not be helpful in managing nausea and vomiting associated with chemotherapy. In fact, high-fibre foods can sometimes contribute to gastrointestinal discomfort, bloating, or constipation, which may worsen nausea in certain individuals. Therefore, fibre-rich foods are not the best option for reducing nausea and vomiting in this scenario.
C) Drink clear and carbonated beverages: Drinking clear liquids, such as water, ginger ale, or clear broths, can help reduce nausea by keeping the client hydrated and soothing the stomach. Carbonated beverages, such as ginger ale, are often recommended because the bubbles can help alleviate nausea and provide some relief. This is a well-established strategy for managing chemotherapy-related nausea and vomiting.
D) Walk frequently throughout the day: While physical activity is generally beneficial for overall health, walking frequently may not directly address nausea and vomiting caused by chemotherapy. In some cases, walking might even worsen nausea if the client is feeling weak or dizzy. Resting and staying hydrated may be more beneficial in the management of nausea associated with chemotherapy.
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