Which step of the nursing process is being performed by the nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR)?

Assessment

Implementation

Diagnosis

Evaluation

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct choice because assessment is the step of the nursing process that involves collecting and organizing data about the patient's health status and needs. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is performing an assessment by gathering relevant information from the patient and other sources.

Choice B reason: This is an incorrect choice because implementation is the step of the nursing process that involves carrying out the planned nursing interventions to achieve the patient's goals and outcomes. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is not performing an implementation by executing any actions or treatments for the patient.

Choice C reason: This is an incorrect choice because diagnosis is the step of the nursing process that involves analyzing and interpreting the data to identify the patient's actual or potential health problems. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is not performing a diagnosis by making any judgments or conclusions about the patient's condition.

Choice D reason: This is an incorrect choice because evaluation is the step of the nursing process that involves measuring and comparing the patient's progress and outcomes with the expected goals and outcomes. The nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR) is not performing an evaluation by assessing any changes or improvements in the patient's status.

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Correct Answer is B

Explanation

Choice A reason: This is incorrect. The Agency for Healthcare Research and Quality is a federal agency that supports research and improvement of health care quality and safety, but it does not provide treatment guidelines for acetaminophen overdose.

Choice B reason: This is correct. The American Association of Poison Control Centers is a national organization that provides poison information and treatment recommendations through a network of poison centers. The nurse can call the poison center at 1-800-222-1222 to get expert advice on how to manage the patient who took 60 acetaminophen tablets.

Choice C reason: This is incorrect. The Centers for Disease Control and Prevention is a federal agency that monitors and prevents diseases and public health threats, but it does not provide treatment guidelines for acetaminophen overdose.

Choice D reason: This is incorrect. The Institute for Safe Medication Practices is a nonprofit organization that promotes safe medication practices and error prevention, but it does not provide treatment guidelines for acetaminophen overdose.

A. Turn on the television to drown out noise from other patients. B. Institute a unit-wide quiet time at 10:00 p.m. each night. C. Reduce the number of visitors to the patient’s room. D. Provide a dedicated period of rest time each afternoon. E. Coordinate therapies and tests with other departments and providers.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A reason: This is incorrect. Turning on the television to drown out noise from other patients can worsen the sensory overload by adding more auditory stimulation. The patient may prefer a quiet and calm environment.

Choice B reason: This is correct. Instituting a unit-wide quiet time at 10:00 p.m. each night can benefit the patient by reducing the noise level and promoting rest and relaxation. The patient may sleep better and feel less agitated.

Choice C reason: This is correct. Reducing the number of visitors to the patient’s room can benefit the patient by minimizing the social and emotional demands and allowing the patient to have some privacy and personal space. The patient may feel less overwhelmed and more comfortable.

Choice D reason: This is correct. Providing a dedicated period of rest time each afternoon can benefit the patient by giving the patient a break from the sensory input and activities of the day. The patient may use this time to meditate, listen to soothing music, or do other calming activities.

Choice E reason: This is correct. Coordinating therapies and tests with other departments and providers can benefit the patient by avoiding unnecessary duplication or interruption of services and ensuring a smooth and consistent care plan. The patient may feel less stressed and more confident.

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Which step of the nursing process is being performed by the nurse who carefully enters a new patient’s medical history and current medication list into the agency’s electronic health record (EHR)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who took 60 acetaminophen tablets. Which resource will the nurse contact for treatment guidelines when the patient arrives in the emergency room?

Correct Answer is B

Explanation

The nurse is caring for a patient who becomes agitated when visitors stay for extended periods or the hospital unit becomes noisy. The nurse identifies this as sensory overload. Which interventions will be of benefit to the patient? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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