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 A

Explanation

Choice A rationale

This statement provides objective and descriptive information about the patient's condition following the venipuncture. It accurately describes the physical findings (painful, raised hematoma) and the location (outer left arm) and clearly links it to the medical procedure (after venipuncture) without making assumptions or assigning blame.

Choice B rationale

This statement is inappropriate as it is judgmental and accusatory towards the laboratory technician. Medical documentation should be objective and focus on the patient's condition and care, not on personal opinions or unsubstantiated claims about the skills of healthcare professionals.

Choice C rationale

This statement is speculative and attempts to explain the cause of the hematoma without factual basis. While patient movement can contribute to bruising, stating it as a likely cause without evidence is not objective documentation and could be inaccurate.

Choice D rationale

While this statement is factual in that it describes the presence of a bruise, it lacks important details such as the size, characteristics (e.g., raised, painful), and its direct association with the venipuncture, which are relevant for a comprehensive patient record.

A. Performing a physical examination. B. Establishing priorities for outcomes. C. Demonstrating diagnostic reasoning. D. Setting time frames for interventions.

Correct Answer is A

Explanation

Choice A rationale

Performing a physical examination involves the systematic assessment of a patient's body to identify signs of health or illness. Listening to lung sounds, palpating peripheral pulses, and obtaining vital signs are all fundamental components of a physical examination aimed at gathering objective data about the patient's current condition.

Choice B rationale

Establishing priorities for outcomes involves setting goals for patient care based on identified nursing diagnoses and collaborative problems. While the nurse's assessment data will inform the development of outcomes, the initial actions described focus on data collection, not outcome identification.

Choice C rationale

Demonstrating diagnostic reasoning is the cognitive process of analyzing assessment data to arrive at a nursing diagnosis or identify a collaborative problem. While the nurse is gathering data that will contribute to diagnostic reasoning, the actions described are the data collection phase itself, not the analysis.

Choice D rationale

Setting time frames for interventions involves establishing specific schedules for nursing actions aimed at achieving patient outcomes. The nurse's immediate actions upon the patient's arrival are focused on rapid assessment to understand the patient's immediate needs, not on scheduling future interventions.

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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 laboratory technician must have had a hard time getting the blood sample drawn as the patient's arm is now bruised.The patient developed a large hematoma where the laboratory technician had drawn blood earlier in the shift.Which statement is appropriate to enter in the patient's chart?

Correct Answer is A

Explanation

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Correct Answer is A

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?