A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?

Re-collection of data

Implementation

Evaluation

Data Collection

Answer and Explanation

The Correct Answer is B

Explanation:

A. Re-collection of data:

This step involves gathering additional information or data about the client's condition. It may be necessary if there are new developments, changes in the client's status, or if the initial data collected was insufficient or inaccurate. Re-collection of data helps ensure that the nurse has comprehensive and accurate information to base the care plan on.

B. Implementation:

Implementation is the phase where the nurse puts the planned interventions into action. This step involves performing nursing actions, administering treatments or medications, providing education and support to the client and their family, and collaborating with other healthcare team members. The nurse follows the care plan developed during the planning phase to address the client's needs and achieve desired outcomes.

C. Evaluation:

Evaluation is the final step of the nursing process where the nurse assesses the client's response to interventions and the effectiveness of the care provided. The nurse compares the client's actual outcomes with the expected outcomes identified during the planning phase. If the outcomes are met, the plan may continue as is or be modified for ongoing care. If the outcomes are not met, the nurse revises the plan as necessary to improve client outcomes.

D. Data Collection:

Data collection is the initial step of the nursing process where the nurse gathers information about the client's health status, including physical, emotional, social, and environmental factors. This step involves conducting assessments, gathering medical history, reviewing laboratory and diagnostic tests, and obtaining information from the client and their family. Data collection forms the basis for identifying nursing diagnoses, developing care plans, and implementing appropriate interventions.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Grab bars are installed in the bathroom:

Correct placement of grab bars in the bathroom can enhance safety for individuals who have mobility challenges, such as those who have experienced a stroke. This is not a safety hazard but rather a safety measure.

B. Medications are stored in a clear bag:

Storing medications in a clear bag may increase the risk of accidental misuse or confusion, particularly for a stroke client who may have cognitive or visual impairments.

C. Area rugs are placed in the living room:

Area rugs can be a safety hazard, especially for individuals with mobility issues or those at risk of falls. Rugs can cause tripping hazards if they are not properly secured or if there are wrinkles or uneven surfaces.

D. Dim lighting installed throughout the house:

Dim lighting can contribute to safety hazards, particularly for individuals with visual impairments or mobility challenges. Insufficient lighting increases the risk of falls and accidents, especially in areas such as staircases, hallways, and bathrooms.

E. The hot water heater is set at 54°C (130° F):

Water temperature set at 54°C (130° F) is excessively hot and poses a scalding hazard, especially for individuals with sensory impairments or reduced ability to perceive temperature changes. Lowering the water heater temperature to a safer range is recommended to prevent scalding injuries.

A. Administer the Hamilton depression scale. B. Make a contract with the client for weight gain. C. Review the client's toxicology laboratory report. D. Initiate one-to-one nursing observation.

Correct Answer is D

Explanation

Explanation:

A. Administer the Hamilton depression scale:

The Hamilton Depression Rating Scale is a tool used to assess the severity of depression symptoms in individuals. While assessing the client's depression level is an important aspect of mental health assessment, it is not the immediate priority in this scenario. The client has been admitted following a suicide attempt, indicating an acute risk to their safety. Therefore, the priority at this stage is to ensure the client's safety and prevent any further harm or attempts at self-harm.

B. Make a contract with the client for weight gain:

Making a contract with the client for weight gain, especially in the context of anorexia nervosa, may be an important aspect of the client's overall treatment plan. However, in this scenario, the client's immediate safety takes precedence. The client has a history of depression, substance abuse, and anorexia nervosa, and the primary concern at admission is to prevent any further self-harm or suicide attempts.

C. Review the client's toxicology laboratory report:

Reviewing the client's toxicology laboratory report is important for understanding any recent substance abuse and its potential impact on the client's physical and mental health. However, while this information is relevant to the client's overall care, it is not the first action to take upon admission. The immediate priority is to ensure the client's safety and provide appropriate monitoring and intervention to prevent further harm.

D. Initiate one-to-one nursing observation:

This is the correct answer. Initiating one-to-one nursing observation means assigning a dedicated nurse to continuously monitor and supervise the client closely. This level of observation is crucial in a situation where there is a history of suicide attempt and ongoing risk of self-harm. One-to-one observation allows for immediate intervention if the client shows signs of distress or attempts to harm themselves, ensuring their safety while they are in the acute mental health unit.

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A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?

Nursing Test Bank

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A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for them? (Select All that Apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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Correct Answer is D

Explanation

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A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next?