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 D
Explanation
A. Use open-ended questions:
Open-ended questions are typically avoided when communicating with aphasic patients. These questions require more complex responses, which might be difficult for someone with language impairments.
B. Not assume that the patient can understand what is heard:
This is a prudent approach. Assuming comprehension without confirmation can lead to misunderstandings. It's better to confirm understanding through non-verbal cues or other communication methods.
C. Talk to the family instead:
While involving family members is important, it doesn't replace direct communication with the patient. The nurse should attempt to communicate directly with the patient, using appropriate techniques.
D. Ask one question at a time:
This is the most suitable option. Asking one question at a time allows the patient to focus on a specific topic and respond more effectively, especially if they have difficulty processing complex information.
Correct Answer is B
Explanation
A. Developed by an RN:
This option suggests that an RN (Registered Nurse) is solely responsible for creating the initial care plan. While nurses significantly contribute to the care plan, it is often a collaborative effort involving various healthcare professionals, including doctors, nurses, and other specialists.
B. Completed on the day of admission:
This choice means that the initial care plan, outlining the patient's immediate healthcare needs and interventions, is developed and documented on the day the patient is admitted to the healthcare facility. It's essential to establish a plan promptly to ensure the patient receives appropriate and timely care.
C. Used as the basis of care throughout a hospital stay without alteration:
This option suggests that the initial care plan remains unchanged throughout the patient's hospital stay. However, healthcare plans need to be dynamic, adapting to the patient's evolving condition. Care plans are continuously assessed and modified based on the patient's response to treatments and interventions.
D. Developed by the primary care provider and incorporated into the nursing care:
This choice implies that the initial care plan is created by the primary care provider (which could be a doctor) and then integrated into the nursing care. While doctors provide medical diagnoses and orders, nurses play a crucial role in implementing and coordinating the care plan, ensuring the patient's needs are met.
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