The nurse is caring for a nonverbal client who is moaning with position changes, the hands and teeth are clenched, and the skin is very diaphoretic.
The nurse interprets this as the client is experiencing pain and decides to administer an analgesic.
What is the correct term for this nursing action?
Setting priorities.
Recognizing inconsistencies.
Making inferences.
Using empathy.
The Correct Answer is C
Choice A rationale
Setting priorities involves deciding the order in which nursing interventions should be implemented based on the urgency and importance of the client's needs. While addressing pain is often a high priority, the term itself doesn't specifically describe the cognitive process of interpreting nonverbal cues as pain.
Choice B rationale
Recognizing inconsistencies involves identifying discrepancies between verbal and nonverbal cues, or between the client's stated condition and observed behaviors. While the nurse is observing nonverbal cues, the primary action here is interpreting those cues, not necessarily identifying inconsistencies.
Choice C rationale
Making inferences involves interpreting cues and drawing conclusions based on available data. The nurse observes the client's moaning, clenched hands and teeth, and diaphoresis, and infers that these signs indicate the presence of pain. This interpretation then guides the decision to administer an analgesic.
Choice D rationale
Using empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing care and may contribute to the nurse's interpretation of the client's distress, the specific cognitive process of interpreting the nonverbal cues as pain is termed making inferences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
While face-to-face hand-off reports are often preferred for direct communication and clarification, they are not always the only acceptable method. Other methods, such as recorded reports or written summaries with opportunities for questions, can also be effective in ensuring continuity of care, especially in situations where face-to-face reporting is not feasible.
Choice B rationale
Providing for the continuity and individualized care of the patient is a primary purpose of hand-off reports. By sharing relevant information about the patient's current condition, care plan, and any recent changes, the hand-off ensures that the receiving nurse has the necessary information to provide consistent and tailored care.
Choice C rationale
Including an opportunity for the receiver to ask questions of the person giving the report is crucial for effective communication and to clarify any ambiguities or obtain additional details. This interactive element helps ensure that the receiving nurse fully understands the patient's situation and can provide safe and appropriate care.
Choice D rationale
Hand-off reports should include up-to-date and recent changes about the patient's condition, treatments, and any new orders or concerns. This ensures that the receiving nurse is aware of the most current information and can adjust care accordingly. Outdated information can lead to errors or omissions in care.
Choice E rationale
Hand-off reports supplement, but do not replace, formal documentation in the patient's medical record. Documentation provides a comprehensive and permanent record of the patient's care, while the hand-off report is a verbal or brief written communication to ensure a smooth transition of care between nurses. Both are essential for effective patient care and communication.
Correct Answer is A
Explanation
Choice A rationale
Impaired gas exchange directly affects the patient's oxygenation and carbon dioxide elimination, which are fundamental physiological needs. Alveolar inflammation and infection in pneumonia disrupt the normal diffusion of gases in the lungs, potentially leading to hypoxemia and hypercapnia, posing an immediate threat to life if not addressed promptly. Normal partial pressure of oxygen (PaO₂) is 80-100 mmHg, and normal partial pressure of carbon dioxide (PaCO₂) is 35-45 mmHg.
Choice B rationale
Pruritus, or itching, while uncomfortable, is a symptom related to medication side effects and does not directly compromise vital physiological functions like gas exchange. Addressing the underlying cause and providing symptomatic relief are important but are a lower priority than ensuring adequate oxygenation.
Choice C rationale
Knowledge deficit regarding risk factors for pneumonia is important for long-term health management and prevention of future episodes. However, in the acute phase of pneumonia, the immediate physiological compromise of impaired gas exchange takes precedence over addressing knowledge gaps.
Choice D rationale
Activity intolerance due to fatigue and shortness of breath is a consequence of the physiological changes associated with pneumonia, primarily the impaired gas exchange. While it affects the patient's quality of life, it is a manifestation of the primary problem rather than the most immediate threat to physiological stability.
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