The nurse is providing end-of-life care and determines the client is experiencing anxiety about the future. Which portion of the nursing process should the nurse use to guide the plan of care?

Planning.

Assessment.

Analysis.

Implementation.

Answer and Explanation

The Correct Answer is A

A. Planning: The planning phase involves setting goals and selecting interventions to address the client’s identified problems, such as anxiety about the future. Once anxiety is recognized, the nurse uses this phase to determine appropriate emotional, spiritual, and psychosocial support strategies.

B. Assessment: Assessment involves collecting data to understand the client's physical, emotional, and psychological condition. While important, it precedes the creation of a care plan and is not the step where interventions are decided.

C. Analysis: Also referred to as nursing diagnosis, this phase interprets assessment data to identify the client’s actual or potential problems. It is a foundation for planning but does not involve selecting or implementing care actions.

D. Implementation: This phase is where the nurse carries out the planned interventions. It follows planning and is focused on action, not on deciding what care strategies to use.

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Correct Answer is B

Explanation

A. Document in the nurses' notes that the dorsalis pedis pulse is not palpable: It is premature to document absence of the pulse without first verifying technique. Inaccurate or excessive pressure may prevent detection of a normal pulse, so further assessment is warranted before recording.

B. Reduce the amount of pressure being applied on the top of the foot: Dorsalis pedis pulses are often faint and can be occluded by pressing too hard. Lightening the pressure increases the likelihood of feeling a subtle pulse if it is present, making this the most appropriate immediate action.

C. Obtain a doppler stethoscope to auscultate the pulse at the same site: A Doppler is useful if the pulse remains nonpalpable after adjusting technique. However, it is not the first step before trying a more refined palpation approach.

D. Palpate the site on the inner side of the ankle below the medial malleolus: This assesses the posterior tibial pulse, which is different from the dorsalis pedis. It may help evaluate overall perfusion but does not resolve the initial concern with palpating the dorsalis pedis pulse.

A. An older adult with left sided weakness. B. An adult client with enuresis C. An adult client with polyuria. D. An older adult with a right hip fracture.

Correct Answer is D

Explanation

A. An older adult with left sided weakness: This client may require assistance to ambulate or use a bedside commode, but depending on strength and stability, they might still be able to use the toilet with support rather than needing a bedpan.

B. An adult client with enuresis: Enuresis refers to involuntary urination, often during sleep. This condition is not an indication for a bedpan, as the focus would be on continence management rather than assisted toileting.

C. An adult client with polyuria: Increased urine output due to polyuria does not necessarily impair mobility. Unless the client is immobile, they can use a toilet or commode rather than a bedpan.

D. An older adult with a right hip fracture: A hip fracture significantly impairs mobility and weight-bearing ability, making it unsafe to ambulate to the bathroom or commode. A bedpan is typically required until mobility is restored or stabilized.

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The nurse is providing end-of-life care and determines the client is experiencing anxiety about the future. Which portion of the nursing process should the nurse use to guide the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?

Correct Answer is B

Explanation

The nurse is planning care for the elimination needs of a group of clients. The nurse determines a bedpan will be needed for which client?

Correct Answer is D

Explanation

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