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. Objective:
Objective data refers to measurable and observable information, often obtained through assessments, tests, or observations. It includes vital signs, laboratory results, physical examination findings, and other data that can be quantified and documented. For example, a blood pressure reading, a recorded temperature, or the observation of a patient's skin color are objective data points.
B. Unreliable:
Unreliable data refer to information that cannot be trusted or depended upon due to its inconsistency or lack of credibility. If a patient provides information that is conflicting, constantly changing, or not coherent, it might be considered unreliable. In healthcare, it's crucial for data to be reliable to ensure accurate diagnosis and treatment.
C. Subjective:
Subjective data are patient-reported information based on their own feelings, experiences, or opinions. This information cannot be measured or observed by others and is typically obtained through patient interviews. Symptoms like pain, headache, or nausea fall into the category of subjective data because they are felt and described by the patient but cannot be independently verified by the healthcare provider.
D. Historical:
Historical data pertain to a patient's past medical history, including previous illnesses, surgeries, allergies, medications, and family medical history. It provides context for the patient's current health status and aids healthcare providers in understanding the patient's overall health background.
Correct Answer is ["1.33"]
Explanation
To calculate the amount of medication the nurse should give, you can use the formula:
Amount to Give (in ml) = Dose Required (in mg) / Concentration (in mg/ml)
In this case:
Dose Required = 400 mg
Concentration = 300 mg/ml
Now, plug these values into the formula:
Amount to Give (in ml) = 400 mg / 300 mg/ml ≈ 1.33 ml
The nurse should give approximately 1.33 ml of the medication.
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