A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?
Client is asleep and resting
Client had 150 mL of emesis in last hour
Ondansetron 4 mg IV bolus for nausea and vomiting
Client reports nausea and vomiting 30 minutes following surgery
The Correct Answer is C
A. This statement pertains to the client's current state but does not represent an intervention taken by the nurse. It would be more appropriate for documentation in a narrative or assessment section rather than the intervention component.
B. This entry describes an outcome or finding related to the client’s condition rather than an intervention. While it is important data, it does not reflect an action taken by the nurse and thus would not be included in the intervention section.
C. It clearly describes a specific action taken by the nurse (administering medication) in response to the problem (nausea and vomiting). It directly addresses the client's needs and reflects an intervention aimed at treating the identified problem.
D. This statement indicates the problem or symptom that the client is experiencing but does not describe an intervention. While it is critical information for understanding the client’s condition, it belongs in the problem or assessment section rather than the intervention component.
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Related Questions
Correct Answer is D
Explanation
A. Holding the cane on the same side as the affected leg can decrease balance and support, making walking more difficult and unsafe.
B. Holding the cane behind the body can lead to instability and increase the risk of falls. The cane should be positioned forward and to the side for better support.
C. While it may seem balanced, it doesn't provide optimal support. The cane should be held to the side for better weight distribution and balance.
D. Holding the cane on the opposite side of the affected leg provides maximum stability and support. The general rule is to move the cane and the affected leg together, allowing for better balance while walking.
Correct Answer is B
Explanation
A. Glaucoma typically affects peripheral vision first and may lead to tunnel vision as the disease progresses. While it can cause significant vision loss, it is not primarily characterized by a decrease in central vision.
B. Macular degeneration specifically affects the central part of the retina (the macula), leading to a loss of central vision while peripheral vision remains intact. It is the most common cause of vision loss in older adults and directly correlates with the symptom described.
C. Diabetic retinopathy primarily affects the blood vessels in the retina and can lead to various vision problems, including blurred vision, floaters, and even blindness. However, it does not exclusively cause a decrease in central vision; it often affects both central and peripheral vision.
D. Cataracts typically cause cloudy or blurred vision but do not specifically lead to a decrease in central vision alone. They may affect overall vision clarity, including both central and peripheral vision, but the primary symptom is a general haziness rather than a focused loss of central vision.
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