Fundamentals of Nursing, Nursing Process *Q&A* [verified]

Fundamentals of Nursing, Nursing Process *Q&A* [verified] A client comes to the walk-in clinic with reports of abdominal pain and diarrhea. While taking the client's vital signs, the nurse is implementing which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Implementation *Ans* A. Assessment Rationale: The first step in the nursing process is assessment, the process of collecting data. All subsequent phases of the nursing process (options 2, 3, and 4) rely on accurate and complete data. The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data? A. The client reports abdominal pain B. The client's urine output was 450 mL C. The client states, "I didn't see any stones in my urine." D. The client states, "I feel like I have passed a stone." *Ans* B. The client's urine output was 450 mL. Rationale: Objective data is measurable data that can be seen, heard, or verified by the nurse. The objective data is the measurement of the urine output. A client's statements and reports of symptoms are documented as subjective data, such as the data found in options 1, 3, and 4. When evaluating an elderly client's blood pressure (BP) of 146/78 mmHg, the nurse does which of the following before determining whether the BP is normal or represents hypertension? A. Compare this reading against defined standards B. Compare the reading with one taken in the opposite arm C. Determine gaps in the vital signs in the client record D. Compare the current measurement with previous ones *Ans* A. Compare this reading against defined Rationale: Analysis of the client's BP requires knowledge of the normal BP range for an older adult. The nurse compares the client's data against identified standards to determine whether this reading is normal or abnormal. Measuring the BP in the other arm (option 2) and comparing the reading to previous ones (option 4) will give additional client data, but the comparison alone will not determine whether the BP is normal. Gaps in the record (option 3) will not aid in interpreting the current measurement. Which of the following behaviors by the nurse demonstrates that the nurse is participating in critical thinking? Select all that apply. A. Admitting not knowing how to do a procedure and requesting help