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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Providing additional written instructions is a helpful teaching strategy but does not directly demonstrate the patient's ability to self-administer the injection correctly. It addresses the teaching method, not the outcome of the teaching.

Choice B rationale

The patient denying concerns does not necessarily indicate successful learning. The patient might have unexpressed concerns or may not fully understand the procedure despite verbalizing otherwise. This statement reflects the patient's verbalization, not their demonstrated skill.

Choice C rationale

The patient correctly self-administering their next scheduled dose of insulin is the most direct and reliable evidence that the teaching was successful. It demonstrates that the patient has acquired the necessary knowledge and skills to perform the injection safely and accurately in a real-life situation.

Choice D rationale

Identifying the steps and equipment used indicates that the patient has some understanding of the procedure. However, it does not guarantee that they can perform the injection correctly. Practical demonstration is required to confirm successful learning of a psychomotor skill.

A. Orientation. B. Termination. C. Working. D. Pre-interaction. E. Evaluation.

Correct Answer is C

Explanation

Choice A rationale

The orientation phase of the interview typically involves introducing oneself, explaining the purpose of the interview, and establishing rapport with the patient. Asking about the drug list occurs after this initial introduction.

Choice B rationale

The termination phase is the concluding part of the interview, where the nurse summarizes key information and discusses the plan of care. Medication history is gathered much earlier in the assessment.

Choice C rationale

The working phase is where the nurse actively collects data about the patient's health history, current condition, medications, and other relevant information. Asking about the drug list, including herbal supplements and over-the-counter medications, is a key component of this data gathering process.

Choice D rationale

The pre-interaction phase occurs before meeting the patient and involves the nurse reviewing available information such as the patient's chart. The actual questioning of the patient happens later.

Choice E rationale

The evaluation phase occurs after interventions have been implemented to assess their effectiveness. It is not the phase where the initial assessment and data collection, including medication history, take place. .

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has just completed teaching the patient how to self-administer insulin injections.Which entry in the patient’s chart demonstrates that the teaching was successful?

Correct Answer is C

Explanation

The nurse completes the assessment for a patient who has just been admitted to the hospital.The nurse carefully documents the patient's current drug list and asks about the use of any herbal supplements or over-the-counter medications.Which phase of the interview does this occur in?

Correct Answer is C

Explanation

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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?