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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Related Questions
Correct Answer is D
Explanation
A. Closed Body Posture:
Active listening often involves open body language, where the listener appears receptive and engaged. Closed body posture, where arms are crossed and body faces away, can indicate disinterest or disagreement, which is not a characteristic of active listening.
B. Three Senses - Sight, Hearing, and Touch:
Active listening primarily involves the sense of hearing. While non-verbal cues like facial expressions and body language are important, active listening doesn't necessarily include touch or sight as direct senses employed during the process.
C. Only Verbal Messages:
Active listening involves not only hearing the words spoken but also understanding the emotions, intentions, and concerns behind those words. It includes interpreting verbal and non-verbal cues, making it more than just processing verbal messages.
D. Focused Energy:
Active listening does require focused energy. It means being mentally present, concentrating on the speaker, and showing genuine interest in what they are saying. This focus allows the listener to comprehend the message and respond appropriately.
Correct Answer is ["B","D","E"]
Explanation
A. Administering pain medication: Administering medication typically requires a healthcare provider's order. Nurses can administer medications, but this action is not independent; it relies on a prescription.
B. Teaching a patient how to change their dressing before they are discharged: This is an independent nursing action. Nurses are educated and trained to provide patient education. Teaching patients about wound care and dressing changes falls under their scope of practice and doesn't require a physician's order.
C. Changing a patient's diet from pureed to regular: Changing a patient's diet usually involves dietary guidelines set by a healthcare provider. Nurses can implement these dietary changes based on the provider's orders but cannot independently change a patient's diet without an order from a healthcare provider.
D. Giving a back rub: Providing comfort measures like a back rub is an independent nursing action. It falls under the domain of holistic nursing care and doesn't require a specific physician's order. Nurses often use such measures to promote relaxation and alleviate discomfort.
E. Repositioning a patient in bed: This is an independent nursing action. Regular repositioning is crucial for preventing pressure ulcers and maintaining a patient's comfort. Nurses assess the patient's mobility and reposition them as needed without requiring specific orders each time.
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