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- A registered nurse is writing a diagnosis for a 28-year-oldmale patient who is in traction due to multiple fractures froma motor vehicle accident. Which nursing actions are related tothis step in the nursing process? Select all that apply.a. The nurse uses the nursing interview to collect patient data.b. The nurse analyzes data collected in the nursing assessment.c. The nurse develops a care plan for the patient.d. The nurse points out the patient’s strengths.e. The nurse assesses the patient’s mental status.f. The nurse identifies community resources to help hisfamily cope.what component of the health history would you place data on a chronic childhood illness? 6. You are collecting data for a comprehensive health history on a patient new to your clinic. Under Past history b. a, Health maintenance General information d. Risk factors с. ANSWER: RATIONALE: 7. A nurse is evaluating a young adult patient who has presented to the emergency department with the chief complaint of abdominal pain. If the nurse is using the PQRSTU method of pain assessment, which of the following questions should be asked for the "S" portion of the assessment? a. "How did your pain start?" and "Is there anything that you can do that stops your pain?" D. "Have you ever had these same symptoms previously?" and "Do you have a history of a previous abdominal surgery?" "How severe is your pain on scale of 1 to 10, where 1 is minimal pain and 10 is the most intense pain?" and "Are you experiencing any other symptoms in addition to your pain?" d. "Tell me more about your pain: is it…Below are terms connected to Ida Jean Orlando’s Nursing Process. In your own words, I want you to give a brief explanation (1-2 sentences) per term as it is significant to the said theory. a. Distress b. Nursing Role c. Nursing Action
- A nurse is preparing an infant and his family for a herniarepair to be performed in an ambulatory care facility.What is the primary role of the nurse during the admissionprocess?a. Assist with screening tests.b. Provide patient teaching.c. Assess what has been done and what still needs to be done.d. Assist with hernia repair.3. _Nurse Charlize jointly set the goal with the Macaspac family in terms of removing the accident hazard in the home specifically the broken stairs observed in the house of the family. After implementing the interventions appropriate to the goal and objectives, you are set to do an evaluation. What will be the main method of evaluation that you will use to determine if the goal was achieved? SELECT ALL THAT APPLIES Records review Interview Observation None of the above.Below are terms connected to Ida Jean Orlando’s Nursing Process. In your own words, I want you to give a brief explanation (1-2 sentences) per term as it is significant to the said theory. a. Distress b. Nursing Role c. Nursing Action d. outcome
- 1. What is the least component of the documentation system? a. Admission assessment b. Problem list c. Care plan or critical pathway d. Flow sheets 2. What contains a complete patient profile and history? a. Admission assessment b. Problem list c. Care plan or critical pathway d. Flow sheets 3. Where do list of actual and potential health problems appear? a. Admission assessment b. Problem list c. Care plan or critical pathway d. Flow sheets 4. What is individualized care plan for each patient mean? a. Admission assessment b. Problem list c. Care plan or critical pathway d. Bed sheets 5. Where do you find the list of observations? a. Check list b. Problem list c. Flow sheets d. Bed sheets 6. What do you call the summary or report written at the time of patient discharge or transfer? a. Check summary b. Discharge summary c. Billing statement d. None of the aboveDuring an interaction with a patient diagnosed with epilepsy,a nurse notes that the patient is silent after she communicatesthe plan of care. What would be appropriate nurse responsesin this situation? Select all that apply.a. Fill the silence with lighter conversation directed at thepatient. b. Use the time to perform the care that is needed uninter-rupted. c. Discuss the silence with the patient to ascertain its mean-ing. d. Allow the patient time to think and explore inner thoughts.e. Determine if the patient’s culture requires pauses betweenconversation. f. Arrange for a counselor to help the patient cope with emo-tional issues.Which among the statements is true about second level assessment in Family Health Nursing? a. Defines the nature of the health problem that the family encounters in performing the health tasks. b. Defines the nature of the health problem that the family encounters in performing the health tasks. c. lt defines the barriers to the family's assumption of these tasks. d. All the options listed e. It defines the etiology to the failure to accomplish the tasks.
- 7. As the nurse caring for a patient you have completed the collection of the subjective data. On what do you base your decision to do an entire head-to-toe physical assessment or a systems-specific assessment? The patient's answers b. Observable signs and symptoms Your knowledge base and expertise d. The patient's chief complaint ANSWER: a. C. RATIONALE: 8. For each patient problem you identify you develop and record a plan. What must your plan do? (Mark all that apply.) a. Begin discharge planning b. Include referral to dietician Flow logically from identified diagnoses d. Specify which steps are needed next e. Identify timing of family involvement ANSWER: с. RATIONALE: 9. Your patient tells you that his chief complaint is "fatigue." When obtaining the patient history, what additional information might you want to elicit to try and pinpoint the patient's "real problem"? More information regarding family history More information regarding secondary complaints More information…1. An elderly client had recent surgery and is on bed rest. When planning care for the client, which nursing intervention is included in the care plan? a. Daily assessment of the wound site b. Foot and ankle range-of-motion(ROM) exercises c. Wound cleaning with hydrogen peroxide d. Coughing and deep breathing in the prone positionNote:- CASE 3: A 15-year-old girl who is a victim of physical and sexual abuse is brought to the health carefacility by her mother for a physical examination. She appears scared, tense, and nervous. She requeststhat the nurse not examine certain parts of her body and asks whether her mother could be presentduring the examination. a. Describe actions the nurse should take during the physical examination to make the clientmore comfortable while collecting the required assessment data.b. What questions must the nurse consider to facilitate analysis of data and identification ofareas where additional physical examination data are needed?. Answer