Examine personal beliefs, prejudgment, and areas for professional development related to cultural differences and vulnerable populations. Which client should the nurse plan to assess first? Transferring the client to a long-term care facility will not help the client with the stress of caring for a family at home. Answer: A Explanation: A The nurse evaluates that pain goals for this client have not been met and examines pain relief interventions to determine the problem. Pain control should be addressed fourth. Panic disorder is a sudden attack of terror, accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. Page Ref: 2344 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome: 4.
Both nursing and medical diagnoses are based not only on information gathered, respectively, by the nurse and physician directly during their assessments, but often include data from other sources. Page Ref: 1943 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 3. Obtaining assessment data from another nurse can provide insight and give a picture of how a client has been during the previous shift; however, using only this information to set priorities may negatively impact client outcomes. What factors should the nurse keep in mind when creating this priority list? Page Ref: 1923 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 1. F Sudden Infant Death Syndrome Module 16: Perfusion The Concept of Perfusion 16.
Suggesting that the client avoid elevators will not help the client. Therefore, long teaching sessions would not be appropriate. B Hypothermia Module 21: Tissue Integrity The Concept of Tissue Integrity 21. The nurse explains the need and makes the client as comfortable as possible. Page Ref: 1634 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 2. The client walking with a limp and asking for something to drink would be non-urgent. The client who sees nothing wrong with washing hands several times a day does not recognize that the ritualistic hand washing is a problem.
Telling the client that the nurse cannot help without answers to the questions is true, but can be seen as a threat and would not be considered a therapeutic response. Which nursing action is the most culturally competent? Page Ref: 1898 Cognitive Level: Analyzing Client Need: Psychosocial Integrity Nursing Process: Assessment Learning Outcome: 1. The client has lost 10 pounds, is continuing to experience pain, and is not eating. Page Ref: 1943 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Diagnosis Learning Outcome: 4. Having a second nurse check the medication order is an appropriate action and is considered a method to reduce medication errors.
Identify risk factors and prevention methods associated with phobias. Both nursing and medical diagnoses involve considering client cues as well as standards and norms. Reading about culture and remaining nonjudgmental are strategies that can be incorporated after engaging in a self-awareness inventory. This mother is too upset to distract by smoothing linens. Many people of this culture will consider refusal of something offered as a gesture of courtesy. Denial is an attempt to screen or ignore unacceptable realities by refusing to acknowledge them.
People may be made vulnerable by immigration status. Page Ref: 2685 Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Nursing Process: Evaluation Learning Outcome: 3. Answer: A Explanation: A Nonverbal communication includes silence, touch, eye movement, facial expressions, and body posture. Page Ref: 1941 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Teaching and Learning Learning Outcome: 2. The other statements are accurate and therefore do not require further teaching. Finally, it turns to the nurse's broader roles, focusing on accountability, advocacy, evidence-based practice, healthcare systems, health policy, informatics, legal issues, quality improvement, and safety. Answer: D Explanation: A Many cultures have religious beliefs that prohibit examination by men of the reproductive areas of a female.
In addition, some cultures are quite comfortable with long periods of silence. Use the urgency factor to set time priorities for interventions. Provide a page number to help reader's find your source, such as: p. Distinguish variations of social behaviors found in diverse groups. What should the nurse do first? Mild over-sedation is not a sentinel event as the client is most likely on a ventilator during surgery.
Describe the five phases in the nursing process. Regardless of who is present during the teaching, it is always necessary to make sure that the instructions are understood, but it is difficult to do that before instructions are given. Which cognitive indication of stress is the client demonstrating? A client who is ill cannot be expected to make the majority of decisions about the plan of care, but should be allowed as much autonomy and choice as can be arranged and tolerated. Provide examples of adverse events and the resulting root cause analysis that would be required. They are also sometimes called multidisciplinary plans because they include medical treatments to be performed by different types of healthcare providers. Answer: D Explanation: A The client with little energy reserve is best served by pacing care throughout the shift to allow for rest periods between activities. If there is no page number, use paragraph number, such as: para.