A nurse is developing pain management goals to a post-operative client. Which of the following steps of the nursing process is the nurse performing?

Planning

Assessment

Implementation

Evaluation

Answer and Explanation

The Correct Answer is A

A. Planning: Developing goals is part of the planning phase, where the nurse sets objectives and outcomes for the patient’s care.
B. Assessment: Assessment involves collecting data about the patient’s condition.
C. Implementation: Implementation involves putting the care plan into action.
D. Evaluation: Evaluation involves determining whether the patient has met the goals and outcomes set during the planning phase.

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Correct Answer is C

Explanation

A. Decreased vision but the client is wearing glasses: As long as the client is wearing glasses and can see adequately, decreased vision is not a barrier to learning that would require postponing teaching.
B. Hearing loss, hearing aids are functioning well: With functioning hearing aids, the client should be able to hear and understand the discharge instructions, so this is not a barrier to learning that requires postponement.
C. Language and no access to an interpreter: Without an interpreter, the client may not understand the instructions, which is a significant barrier to learning. This requires postponing the teaching until an interpreter is available.
D. The client's culture: While cultural differences can influence learning, they do not inherently create a barrier that necessitates postponing teaching unless they directly affect comprehension or communication.

A. Speak loudly and use simple words B. Address the client by name and reorient client C. Challenge the client to refocus his attention when he becomes agitated D. Ask the client a series of questions without allowing time for the client to answer

Correct Answer is B

Explanation

A. Speak loudly and use simple words: Speaking loudly may be perceived as shouting and can increase agitation. Using simple words is appropriate, but volume should be normal and calm.
B. Address the client by name and reorient client: Addressing the client by name and reorienting him is effective because it respects his dignity and helps him understand his current situation, reducing confusion and agitation. This approach is clear, respectful, and supportive.
C. Challenge the client to refocus his attention when he becomes agitated: Challenging the client can be confrontational and may escalate agitation. It is better to use a calm, reassuring approach.
D. Ask the client a series of questions without allowing time for the client to answer: This can overwhelm and frustrate the client, leading to increased agitation.

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A nurse is developing pain management goals to a post-operative client. Which of the following steps of the nursing process is the nurse performing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing discharge instructions. Which of the following barriers to learning should the nurse interpret as a need to postpone the teaching?

Correct Answer is C

Explanation

An 84-year-old cognitively-impaired gentleman is admitted from a skilled nursing facility to your acute care facility for increasing agitation and combativeness in the last few days. Which of the following is an example of effective communication with this client?

Correct Answer is B

Explanation

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