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

Answer and Explanation

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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Correct Answer is D

Explanation

A. This is too hot and can scald the client's skin. The recommended water temperature for bathing is around 37-40°C (98.6-104°F).
B. Bath oil can make the bathtub surface slippery, increasing the risk of falls.
C. While it's important to avoid prolonged exposure to hot water, limiting bath time to 20 minutes is not the primary concern for safety in this situation.
D. This is the most important safety measure to prevent falls, especially for a client with a lower extremity amputation who may have balance difficulties.

A. "Are you feeling stressed before you have a headache?" B. "Do you feel nausea when you have your headaches?" C. "We should check your blood pressure when you have a headache." D. "Do any medications relieve your headaches?"

Correct Answer is A

Explanation

A. This statement incorporates an inquiry into the client's emotional and psychological state, recognizing that stress may contribute to headache frequency. It reflects a holistic approach by considering factors beyond the physical symptoms, acknowledging the interplay between mental health and physical well- being.
B. This question focuses specifically on the physical symptoms of the headaches. While it’s important to understand the client’s symptoms, this statement does not consider emotional or psychosocial factors, making it less holistic.
C. Checking blood pressure is a vital assessment related to potential physiological causes of headaches. However, this action is primarily focused on physical health and does not encompass a holistic view of the client’s overall experience or emotional state.
D. This question addresses treatment and management of headaches, focusing on the effectiveness of medication. While important, it does not explore other contributing factors such as lifestyle, emotional health, or stress, and therefore lacks a holistic perspective.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who had a lower extremity amputation with a bath. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who reports frequent headaches. Which of the following statements by the nurse uses holistic nursing?

Correct Answer is A

Explanation

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