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To use the NURSING PROCESS correctly, the nurse must FIRST
A. Identify the goals for the client's care
B. Obtain information about the client
C. State the client's nursing care needs
D. Evaluate the effectiveness of the client's care - 🧠ANSWER ✔✔B. Obtain
information about the client.
,RATIONALE: while stating the client's needs, identifying goals, and evaluating
the effectiveness of the client's care is an appropriate step in the nursing process, it
is not the first step. The collection of data, or assessment, is the first step in the
nursing process.
A 3 YR OLD CHILD has had MULTIPLE TOOTH EXTRACTIONS while under
general anesthesia. The client returns from the PACU crying, but awake, from the
recovery room. Which APPROACH is likely to be successful?
A. Do not examine the mouth
B. Examine the mouth first
C. Examine the mouth last
D. Medicate the child for pain before examining the mouth - 🧠ANSWER ✔✔C.
Examine the mouth last
,RATIONALE: it is always appropriate to leave the most distressing part of a
physical exam of a toddler until the end. Since the mouth is the area of discomfort,
examining it is likely to cause more crying and uncooperative behavior for the
remainder of the assessment.
The child just had oral surgery and is at risk for hemorrhage and swelling. It is
imperative that the mouth be examined. The child must be assessed for pain before
pain medication can be administered.
A nurse is performing an ABDOMINAL ASSESSMENT of an adult client.
Identify the correct sequence of steps used for this assessment.
Auscultation
Inspection
Palpation
Percussion - 🧠ANSWER ✔✔Inspection
Auscultation
Percussion
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, Palpation
RATIONALE: this sequence prevents altering the bowel sounds during an
abdominal assessment. The appropriate sequence for any other assessment of an
adult client is inspection, palpation, percussion, and auscultation.
A nurse is teaching a client who has cardiovascular disease how to reduce his
intake of sodium and cholesterol. The nurse understands that the MOST
SIGNIFICANT factor in PLANNING DIETARY CHANGES for this client is the
A. Involvement of the client in planning the change
B. Emphasis the provider places on the dietary changes
C. Financial ability of the client to make the dietary changes
D. Extent of the dietary changes planned for the client - 🧠ANSWER ✔✔A.
Involvement of the client in planning the change