ADPIE
The nurse is working with a client who has recently been diagnosed with diabetes. The nurse has educated the client and would like to know if the client has understood everything that was discussed. What part of the Nursing Process does this represent?
Evaluation
A client has expressed to the nurse that he has been experiencing depression and has been thinking of self-harm. For the nurse to prioritize she has to use Maslow’s hierarchy of needs. What need is the client lacking?
Self-Esteem
You are a Nurse at a Long Term Care Facility and you are caring for a client who has dementia, needs assistance with ADLs and has had incontinent episodes. Which of the following would be an appropriate Nursing Diagnosis? (Select all that apply)
a. Neurological deficit
b. Impaired mobility
c. Dysphasia
d. Risk for impaired skin integrity
e. Confusion
B, D, E
A nurse making rounds is about to see assigned clients in the Med/Surg unit. Which of the following nursing interventions demonstrates the planning phase of the nursing process?
a. recording the client's fluid input-output
b. determining the client's current range of motion
c. changing a surgical dressing per physician's order
d. creating a mobility regimen with the client
D. creating a mobility regimen with the client - planning
The Nurse recognizes that a client with no home to go to after discharged falls under which category of Maslow’s Hierarchy?
Safety
A Nurse is preparing a care plan for a newly admitted client. When writing the client outcome the nurse must include…. (Select all that apply)
a. the phrase "as evidence by"
b. repetition of the Nursing Diagnosis
c. the phrase "related to"
d. a specific date
e. the client's full name
A, B, D
A nurse administers pain medication per physician's order. Two hours after receiving the dose, the client says she is experiencing strong pain. The nurse reassesses the client's pain level and calls the physician for further instructions. The nurse is using which step of the nursing process?
Evaluation phase
A client is about to be discharged from a rehabilitation facility and be transported home. The client states, “I’m not sure how I will be able to manage getting to my bedroom. It is upstairs, I’m nervous.” Which Maslow’s Hierarchy of Human needs should the nurse consider before discharge?
Safety
Which data is considered objective? Select all that apply.
a. Client complains of abdominal pain
b. Client is febrile
c. Client’s blood pressure is 130/99
d. Client reports angina with history of cardiac complications
e. Client has redness on sacrum
B, C, E