A resident in a nursing home complains of constipation. The nurse checks the patient record and notes that he has not had a bowel movement in three days. She/he then performs a digital rectal exam and feels hard stool. Which part of the nursing process is this?
evaluation
assessment
nursing diagnosis
implementation
The Correct Answer is B
A. Evaluation:
Evaluation involves the assessment of a patient's response to nursing interventions and the effectiveness of the care plan. In this scenario, the nurse is not evaluating the patient's response to previous interventions but is rather in the process of conducting a new assessment.
B. Assessment:
This statement is correct. The nurse is in the assessment phase of the nursing process. She is collecting data by checking the patient's record, performing a physical examination (digital rectal exam), and noting the patient's complaint and signs of constipation (no bowel movement for three days, hard stool). Assessment is the first step of the nursing process and involves data collection to identify health problems and needs.
C. Nursing Diagnosis:
Nursing diagnosis involves analyzing the data collected during the assessment to identify actual or potential health problems. The nurse has not reached the stage of formulating a nursing diagnosis in this scenario; she is still gathering data.
D. Implementation:
Implementation is the phase of the nursing process where nursing interventions are carried out based on the nursing care plan. The nurse is not implementing interventions yet but is still in the process of data collection.
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Correct Answer is C
Explanation
A. Orders for diagnostic and therapeutic procedures such as laboratory tests or x-rays:
This refers to medical orders, which are instructions given by a physician for diagnostic tests or treatments. These orders are not part of the nursing care plan. Nurses execute these orders but do not create them.
B. Laboratory and x-ray reports, pathology reports, and the medication record:
These are patient records and reports. While nurses use this information to inform their care, the reports themselves are not the nursing care plan. Nurses analyze these reports to make informed decisions regarding patient care.
C. Nursing orders for individualized interventions to assist the patient to meet expected outcomes:
This is the correct choice. Nursing care plans involve identifying the patient's nursing diagnoses (health issues that nurses can address), setting specific and measurable outcomes, planning interventions tailored to the patient's needs, and evaluating the outcomes. It's a holistic approach designed to address the patient's unique health challenges.
D. The physician's history and physical examination, as well as medical diagnoses:
This refers to the medical diagnosis and assessment, which are critical for understanding the patient's overall health. While nurses consider this information, the nursing care plan specifically focuses on nursing interventions and care strategies, making it distinct from the medical diagnosis.
Correct Answer is ["A","D"]
Explanation
A. Spoken words: Verbal communication primarily involves the use of spoken words to convey messages.
B. Body language: While body language is a crucial aspect of communication, it is non-verbal communication. Non-verbal communication includes gestures, facial expressions, posture, and eye contact.
C. Gesture: Gestures are also part of non-verbal communication, involving movements of hands or other body parts to express thoughts or feelings.
D. Intonation: Intonation refers to the rising and falling pitch patterns in speech. It conveys nuances of meaning and emotions, enhancing the spoken words. Intonation is a verbal aspect of communication.
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