A. History taking: This refers to the process of gathering information about a patient's medical history, including their symptoms, past illnesses, medications, and family history. It involves asking questions and actively listening to the patient's responses.

B. Palpation of an area: Palpation involves using the hands to feel the body's surface, usually to assess the texture, size, consistency, and location of certain organs or structures. For example, a healthcare provider might palpate the abdomen to feel for any abnormalities or tenderness.

C. Communication: Communication is a broad term that encompasses various aspects of interacting with a patient, including asking questions, active listening, providing explanations, and expressing empathy. Effective communication is crucial for building trust, understanding the patient's concerns, and delivering appropriate care.

D. Weighing of a patient: Weighing a patient is a specific measurement and is not a technique used for a physical examination. However, a patient's weight can be an essential piece of information in understanding their overall health and can be considered during the assessment process.

A. Pain:

Explanation: Pain is a subjective experience because it is based on the patient's feelings and emotions. It varies from person to person and can't be precisely measured or observed by others. Patients often describe their pain based on personal sensations, making it subjective information.

B. Headache:

Explanation: Like pain, a headache is a subjective symptom. Patients report their experience of a headache based on personal sensations, such as throbbing or pressure. It can't be directly measured or observed by healthcare providers; instead, it relies on the patient's description.

C. Lightheadedness:

Explanation: Lightheadedness is another subjective symptom. Patients may feel dizzy or unsteady, but this sensation can't be quantified objectively. It is based on the patient's perception of feeling lightheaded, making it subjective information.

D. Temperature:

Explanation: Temperature is objective data because it can be precisely measured using a thermometer. It provides a specific numerical value, such as 98.6°F (37°C). Objective data is observable and measurable, making temperature a clear example of objective information obtained through examination or assessment.

A. Actions of the nurse are appropriate since his neighbor is his confidante, and the neighbor has assured him the information provided will not be shared.

Explanation: Even if the nurse's neighbor is considered a confidante, sharing specific patient information is still a breach of confidentiality. Healthcare professionals are obligated to follow strict guidelines regarding patient privacy, and sharing patient details with anyone outside the healthcare team, even if they promise not to share it further, is not ethically permissible.

B. The nurse is actively promoting nursing as a profession, and it is important to share information that might encourage others to pursue a nursing career.

Explanation: While it's positive for nurses to encourage others to pursue nursing, this should not involve sharing private patient information. There are many appropriate ways to promote the nursing profession, such as discussing the rewards of the job, the educational paths, or the impact nurses have on patient care. Patient confidentiality, however, should never be compromised in such attempts.

C. The nurse has violated the confidentiality of the patient by discussing personal information about the patient with his neighbor.

Explanation: This is the correct choice. As mentioned earlier, patient confidentiality is a fundamental ethical and legal principle in healthcare. Disclosing personal patient information to unauthorized individuals, even if unintentional or with good intentions, is a violation of this principle.

D. The nurse has not violated the confidentiality of the patient because the patient is terminal: sharing this information will not harm the patient.

Explanation: A patient being terminal does not change the rules of confidentiality. Regardless of a patient's condition, their right to privacy remains intact. Sharing information about a patient's terminal status without proper authorization is still a breach of confidentiality and is not considered ethical practice.

A. Stroke Rehabilitation:

Explanation: Stroke rehabilitation is a long-term goal because it involves a process of recovery and adaptation over an extended period. Stroke survivors often need ongoing therapy, medical management, and support to regain lost functions and improve their quality of life. Achieving the maximum possible recovery can take months or even years, making it a long-term goal in healthcare.
B. Adequate Fluid Intake:

Explanation: Adequate fluid intake is essential for maintaining good health, but it is generally considered a short to medium-term goal. While ensuring a patient's proper hydration is crucial, it is typically resolved within a short timeframe by encouraging the patient to drink more fluids. Health professionals can monitor this relatively easily and make adjustments accordingly, making it a shorter-term goal compared to stroke rehabilitation.
C. Treatment of a Urinary Tract Infection (UTI):

Explanation: Treating a UTI is typically a short-term goal. Once diagnosed, UTIs can be effectively treated with antibiotics. Patients are usually prescribed a course of antibiotics, and symptoms generally improve within a few days. Monitoring the effectiveness of the treatment and ensuring the infection is completely resolved are parts of the short-term care plan.
D. Treatment of Pneumonia:

Explanation: Similar to a UTI, treating pneumonia is usually a short to medium-term goal. Pneumonia often requires a course of antibiotics and supportive care. Patients can experience improvement within a few days to a couple of weeks, depending on the severity of the infection. Monitoring the patient's response to treatment and ensuring complete resolution are essential short to medium-term objectives in pneumonia management.

A. Assessment:

Explanation: Assessment is the first step in the nursing process. It involves gathering information about the patient's health status. This can include a patient's medical history, physical examination, and other vital signs. It's the phase where the nurse collects data to identify the patient's problems or needs.
B. Nursing Diagnosis:

Explanation: Nursing diagnosis is the second step in the nursing process, following assessment. During this step, the nurse analyzes the data collected during the assessment to identify nursing diagnoses or issues. Nursing diagnoses are clinical judgments about individual, family, or community responses to actual or potential health problems or life processes.
C. Evaluation:

Explanation: Evaluation is the last step in the nursing process. It involves assessing the patient's response to nursing interventions and determining if the goals and outcomes have been met. In the given scenario, the nurse is evaluating whether the pain medication administered 45 minutes ago has had the desired effect and has relieved the patient's pain.
D. Implementation:

Explanation: Implementation is the third step in the nursing process. During this phase, the nurse carries out the care plan that was designed during the planning phase. This can involve a variety of nursing actions, including administering medications, providing treatments, and educating patients. In the context of the scenario, giving pain medication is part of the implementation phase.

Here's the breakdown of each step:

Assessment: This is the first step in the nursing process. It involves gathering information about the patient's health status. Assessment can include collecting data through interviews, physical examinations, and reviewing medical records.

Nursing Diagnosis: After assessing the patient, the nurse analyzes the data to identify nursing diagnoses or issues. Nursing diagnoses are clinical judgments about individual, family, or community responses to actual or potential health problems or life processes.

Planning: Based on the nursing diagnosis, the nurse develops a plan of care. This plan outlines the goals and outcomes the nurse hopes to achieve. It also includes interventions, which are the actions the nurse will take to address the nursing diagnoses.

Implementation: During this phase, the nurse puts the plan into action. This can include administering medications, providing treatments, educating patients, and other nursing interventions.

Evaluation: Evaluation is the final step. The nurse assesses the patient's response to nursing interventions and determines if the goals and outcomes have been met. If the goals have not been met, the nurse may need to revise the plan of care.

A. Maintaining skin integrity:
Maintaining skin integrity is crucial for preventing pressure ulcers and other skin-related issues, especially for patients who are bedridden or have limited mobility. Preventive measures, like turning the patient regularly and keeping the skin clean and dry, are essential. While important, it is not always the highest priority and can be managed alongside other nursing interventions.

B. Adequate nutrition:
Providing adequate nutrition is vital for the patient's overall health and recovery. Malnutrition can impair the healing process and weaken the immune system. However, in immediate critical situations, addressing the airway, breathing, and circulation (ABCs) takes precedence over nutritional concerns. Once the patient is stable, addressing nutrition becomes a priority in the nursing care plan.

C. Pain control:
Managing pain is crucial for a patient's comfort and well-being. Uncontrolled pain can cause anxiety, impair healing, and decrease the overall quality of life. Pain control is a high priority, but in certain emergencies where the patient's airway or circulation is compromised, managing pain might be temporarily secondary until the primary issues are addressed.

D. Airway management:
Ensuring a clear airway is often the highest priority in emergency situations. Without a patent airway, the patient cannot breathe effectively, leading to oxygen deprivation and potential cardiac arrest. Nurses and healthcare providers focus on maintaining or establishing a clear airway to ensure the patient can breathe adequately. Once the airway is secured, attention can be directed to other aspects of care.

A. Psychosocial needs should be met first:
Psychosocial needs are undoubtedly essential aspects of patient care. However, the priority of nursing problems depends on the patient's condition and the urgency of the situation. While psychosocial needs are critical, they might not always be the first priority, especially in acute or life-threatening situations. Safety and physiological needs often take precedence.

B. Problems don't need to be prioritized:
In nursing practice, problems do need to be prioritized. Patients usually have multiple issues that need attention, and prioritization ensures that the most urgent or life-threatening problems are addressed first. Without prioritization, critical issues might be delayed, potentially leading to adverse outcomes.

C. Problems should be ranked according to their importance:
This statement is correct. Prioritizing nursing problems involves ranking them based on their importance and urgency. It ensures that the most critical issues are addressed promptly and effectively, enhancing patient outcomes and safety.

D. Safety is the #1 priority:
This statement is also correct. In nursing, patient safety is paramount. Ensuring the patient's safety is the top priority in all situations. This includes assessing and managing risks, preventing accidents or injuries, and providing a safe environment for both patients and healthcare providers. Safety concerns often take precedence over other nursing problems.

A. North American Nursing Diagnosis Association (NANDA) revises the diagnostic labels every 5 years:
This statement is not accurate. The North American Nursing Diagnosis Association (NANDA) International does review and revise the nursing diagnoses regularly, but it's not on a fixed 5-year schedule. Changes are made based on evolving healthcare practices, new research, and emerging health issues.

B. A nursing diagnosis describes a health problem amenable to intervention:
This statement is true. A nursing diagnosis identifies a specific health problem that can be addressed through nursing interventions. It provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.

C. Medical diagnosis is included in the nursing diagnosis:
This statement is incorrect. Nursing diagnoses are distinct from medical diagnoses. Medical diagnoses identify diseases or pathologies, whereas nursing diagnoses focus on the patient's responses to the health condition. Nursing diagnoses are within the domain of nursing practice and are formulated based on nursing assessments.

D. LPNs/LVNs formulate nursing diagnoses:
This statement is generally true. Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) can formulate nursing diagnoses as part of their scope of practice. However, the complexity of the diagnosis and the depth of assessment often determine the level of nurse involved in formulating nursing diagnoses. Registered Nurses (RNs) typically handle more complex patient cases and nursing diagnoses

A. Maslow's hierarchy of needs:
This statement is true. Prioritizing patient problems is often based on Maslow's hierarchy of needs, which categorizes human needs from basic physiological requirements to higher-level psychological needs. Patients' immediate and essential needs, such as airway, breathing, and circulation, are prioritized over other needs based on this framework.

B. The nurse-to-nurse report:
This statement is incorrect. Nurse-to-nurse report is essential for continuity of care, but it is not the basis for prioritizing patient problems. Prioritization is based on the patient's immediate needs and safety concerns.

C. Nonspecific data collection:
This statement is incorrect. Prioritization is based on specific data collected during the assessment, including physiological measurements, symptoms, and patient history. Nonspecific data collection wouldn't provide the necessary information for effective prioritization.

D. Managerial influence:
This statement is incorrect. While managers might provide guidelines and policies, the direct care nurse at the bedside typically prioritizes patient problems based on clinical judgment, immediate needs, and the nursing process.

A. An independent nursing action:
This statement is correct. Preparing a patient for a diagnostic test and providing information about what to expect during and after the test is within the scope of nursing practice. Nurses can independently educate patients and prepare them for procedures based on their knowledge and protocols.

B. The doctor's responsibility:
This statement is incorrect. While doctors order tests and procedures, it is the responsibility of the nursing staff to prepare the patient, provide necessary information, and ensure the patient's understanding and comfort before the procedure.

C. A dependent nursing action that requires the doctor's authorization:
This statement is incorrect. Preparing a patient for a diagnostic test and providing education about the procedure do not require direct authorization from the doctor. Nurses can perform these actions as part of their nursing practice.

D. An interdependent nursing action:
This statement is incorrect. Interdependent nursing actions involve collaboration with other healthcare professionals. Educating the patient about a diagnostic test is primarily an independent nursing action, although collaboration with other team members might be necessary in certain cases.

A. Evaluation:
Evaluation involves the assessment of a patient's response to nursing interventions and the effectiveness of the care plan. In this scenario, the nurse is not evaluating the patient's response to previous interventions but is rather in the process of conducting a new assessment.

B. Assessment:
This statement is correct. The nurse is in the assessment phase of the nursing process. She is collecting data by checking the patient's record, performing a physical examination (digital rectal exam), and noting the patient's complaint and signs of constipation (no bowel movement for three days, hard stool). Assessment is the first step of the nursing process and involves data collection to identify health problems and needs.

C. Nursing Diagnosis:
Nursing diagnosis involves analyzing the data collected during the assessment to identify actual or potential health problems. The nurse has not reached the stage of formulating a nursing diagnosis in this scenario; she is still gathering data.

D. Implementation:
Implementation is the phase of the nursing process where nursing interventions are carried out based on the nursing care plan. The nurse is not implementing interventions yet but is still in the process of data collection.

A. "Don't worry; this pain won't last forever."
This statement dismisses the patient's concerns and does not encourage open communication about pain. It does not address the patient's current pain experience or provide a basis for effective pain management.

B. "You look pretty comfortable. Are you having any pain?"
While this statement attempts to inquire about the patient's pain, it might not encourage the patient to open up about their pain experience. The patient might downplay their pain to appear strong or not to be a bother.

C. "Is this pain the same as the pain you had yesterday?"
This question is specific and might help in assessing the consistency and nature of the pain. However, it assumes the patient had pain yesterday and does not open the conversation effectively for the patient to express their pain experience freely.

D. "Tell me about the pain you've been having."
This statement is open-ended and encourages the patient to express their pain experience in their own words. It creates a comfortable environment for the patient to discuss their pain, allowing the nurse to gather valuable information about the pain's intensity, location, quality, and factors that aggravate or alleviate it. This approach is patient-centered and allows for a comprehensive pain assessment.

A. Comprehensive plan to allow patient access to medical records.

While electronic medical records (EMRs) do facilitate patient access to their medical information, the primary goal of the 2009 American Recovery and Reinvestment Act was broader. It aimed to improve healthcare quality, safety, and efficiency through the promotion of health IT, including EMRs.

B. Comprehensive document of health care costs.

Although EMRs can include billing information, the main purpose of EMRs is to record clinical data for patient care and not specifically to document healthcare costs.

C. Comprehensive plan of care for all patients.

EMRs are tools used by healthcare providers to record patient information and manage healthcare delivery. While they can support the creation and management of care plans, their primary function is to store patient data electronically rather than generating care plans.

D. Correct comprehensive record of a patient's history and care across all facilities and admissions.

This statement best reflects the primary goal of the electronic medical record implementation. EMRs are designed to provide accurate, comprehensive, and up-to-date information about a patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and laboratory test results, among other essential data. They ensure that this information is accessible to authorized healthcare providers across various facilities and admissions, improving continuity of care and patient safety.

A. Make revisions in the plan as indicated by the shift report.
Reviewing the nursing care plan before beginning care allows the nurse to integrate the information from the shift report into the plan. If there are necessary revisions based on the shift report, the nurse can make informed adjustments to the care plan.

B. Skip the shift report and begin with the initial assessment.
Skipping the shift report is not advisable. Shift reports are crucial for continuity of care. The nurse needs to receive information about the patient's condition and ongoing care before starting the shift.

C. Begin nursing interventions without needing an initial assessment.
Starting interventions without an initial assessment can be unsafe and ineffective. Assessments provide the foundation for understanding the patient's current condition and planning appropriate care.

D. Use critical thinking skills to organize care for the patient.
Reviewing the care plan before starting care enables the nurse to utilize critical thinking skills. By understanding the existing care plan and the patient's current status, the nurse can organize and prioritize care effectively, making informed decisions based on the patient's needs and the provided care plan.

A. Administering pain medication: Administering medication typically requires a healthcare provider's order. Nurses can administer medications, but this action is not independent; it relies on a prescription.

B. Teaching a patient how to change their dressing before they are discharged: This is an independent nursing action. Nurses are educated and trained to provide patient education. Teaching patients about wound care and dressing changes falls under their scope of practice and doesn't require a physician's order.

C. Changing a patient's diet from pureed to regular: Changing a patient's diet usually involves dietary guidelines set by a healthcare provider. Nurses can implement these dietary changes based on the provider's orders but cannot independently change a patient's diet without an order from a healthcare provider.

D. Giving a back rub: Providing comfort measures like a back rub is an independent nursing action. It falls under the domain of holistic nursing care and doesn't require a specific physician's order. Nurses often use such measures to promote relaxation and alleviate discomfort.

E. Repositioning a patient in bed: This is an independent nursing action. Regular repositioning is crucial for preventing pressure ulcers and maintaining a patient's comfort. Nurses assess the patient's mobility and reposition them as needed without requiring specific orders each time.

First, let's find out how many milliliters (ml) are needed for a 180 mg dose using the given supply:

{Dose needed} = 180 mg

Supply concentration = 30 mg/5ml

Using the formula:

Volume (ml) = Dose needed (mg/ Supply concentration (mg/ml)

Substituting the values:

Volume (ml) = 180 mg/ 30 mg/5ml

Volume (ml) = (180mg*5ml)/30mg

Volume (ml) = 900/30 ml

Volume (ml) = 30ml

Now, one tablespoon is equal to 15 ml. So, to convert 30 ml to tablespoons:

Number of tablespoons = 30ml/ 15ml

Number of tablespoons = 2

The nurse would give 2 tablespoons.

A. Changing a surgical dressing: This is an example of a nursing implementation. Nurses frequently change dressings as part of their patient care responsibilities.

B. Return demonstration by the patient: This is also an example of a nursing implementation. Nurses often educate patients and then assess their understanding through return demonstrations to ensure the patient can perform tasks correctly at home.

C. Changing an ostomy bag: This is another example of a nursing implementation. It involves hands-on care for patients with ostomies, a responsibility often carried out by nurses.

D. Planning patient outcomes: While planning patient outcomes is crucial for nursing care, it falls more under the category of nursing interventions and nursing process rather than direct implementations.

E. Analyzing assessment data: Analyzing assessment data is part of the nursing process and helps in making decisions about nursing care. While it's essential, it's not a direct implementation action.

A. Reinforces application of the nursing process: True. The Problem-Oriented Medical Record (POMR) is designed to organize patient data based on specific problems, which aligns well with the nursing process. It emphasizes problem-solving and critical thinking in the context of patient care.

B. Formats documentation into chronological order: This is not entirely accurate for POMR. POMR organizes data by problems, not necessarily in strict chronological order. Information is clustered around specific problems, making it easier to identify relevant data quickly.

C. Promotes the problem-solving approach: Yes, this is correct. POMR emphasizes identifying and solving individual patient problems, encouraging a systematic and problem-oriented approach to patient care.

D. Makes tracking trends in patient care easy: This can be true, especially when it comes to tracking the progress of specific problems over time. POMR allows healthcare providers to see the evolution of each problem, making it easier to track trends related to individual issues.

E. Allows for easy auditing of patient records to evaluate staff performance: POMR does facilitate easier auditing since each problem is documented separately, allowing for clear assessment of how each problem is being managed. This can be valuable for evaluating staff performance.

A. The nurse tells the patient not to worry about the surgery: This response dismisses the patient's concerns and does not engage in active listening. It does not encourage the patient to express their feelings or concerns.

B. The nurse assures the patient that the surgeon is very experienced: While this response provides information, it does not actively listen to the patient's concerns. It might be reassuring, but it doesn't engage in a deeper understanding of the patient's feelings.

C. The nurse asks the patient why they are afraid of surgery: This response demonstrates active listening. By asking the patient to express their fears, the nurse is encouraging the patient to talk about their concerns openly. This fosters a therapeutic relationship and allows the nurse to better understand the patient's emotions and address their specific worries.

D. The nurse shares her/his own experience of having surgery: Sharing personal experiences can sometimes be helpful, but in this context, it doesn't actively listen to the patient. It shifts the focus away from the patient's concerns to the nurse's experiences, which might not be relevant or helpful to the patient.

A. Spoken words: Verbal communication primarily involves the use of spoken words to convey messages.

B. Body language: While body language is a crucial aspect of communication, it is non-verbal communication. Non-verbal communication includes gestures, facial expressions, posture, and eye contact.

C. Gesture: Gestures are also part of non-verbal communication, involving movements of hands or other body parts to express thoughts or feelings.

D. Intonation: Intonation refers to the rising and falling pitch patterns in speech. It conveys nuances of meaning and emotions, enhancing the spoken words. Intonation is a verbal aspect of communication.

A. Level of English Literacy:
Understanding the patient's level of English literacy is crucial for effective communication. It helps healthcare providers tailor their communication to ensure the patient comprehends their condition, treatment, and instructions.

B. Dietary Concerns:
Cultural dietary practices and restrictions can significantly impact a patient's nutrition and recovery. Knowing about dietary concerns allows healthcare providers to plan meals that respect the patient's cultural preferences and restrictions.

C. Beliefs About Causality of Illness:
Different cultures have unique beliefs about the causes of illnesses, which can influence their perceptions of healthcare and treatment. Understanding these beliefs helps healthcare providers provide culturally sensitive care and explain medical conditions and treatments in a way that aligns with the patient's beliefs.

D. Number of Children in the Immediate Household:
While this information might be relevant for social context, it's not directly related to cultural factors. However, it could be useful in some cases, such as understanding family dynamics or support systems.

E. Primary Language Spoken:
Knowing the patient's primary language is essential for effective communication. It ensures that healthcare providers can provide accurate information, understand the patient's concerns, and involve interpreters if necessary to bridge language barriers.

A. Closed Body Posture:
Active listening often involves open body language, where the listener appears receptive and engaged. Closed body posture, where arms are crossed and body faces away, can indicate disinterest or disagreement, which is not a characteristic of active listening.

B. Three Senses - Sight, Hearing, and Touch:
Active listening primarily involves the sense of hearing. While non-verbal cues like facial expressions and body language are important, active listening doesn't necessarily include touch or sight as direct senses employed during the process.

C. Only Verbal Messages:
Active listening involves not only hearing the words spoken but also understanding the emotions, intentions, and concerns behind those words. It includes interpreting verbal and non-verbal cues, making it more than just processing verbal messages.

D. Focused Energy:
Active listening does require focused energy. It means being mentally present, concentrating on the speaker, and showing genuine interest in what they are saying. This focus allows the listener to comprehend the message and respond appropriately.

A. Patient leaving against medical advice:
When a patient decides to leave the hospital against medical advice, it's crucial to communicate this decision effectively. However, this situation does not specifically require a structured communication tool like SBAR. Rather, it necessitates clear communication to ensure the patient understands the risks and implications of leaving against medical advice.

B. Patient transfer to another facility:
During a patient transfer, especially between different healthcare facilities, it's essential to provide a comprehensive hand-off communication. SBAR is commonly used in such situations.

Situation: Describes the current situation and why the patient is being transferred.
Background: Provides relevant medical history and context.
Assessment: Presents the patient's current condition and vital signs.
Recommendation: Specifies what care and interventions the receiving facility should provide.
Using SBAR in this context ensures that all critical information is passed on accurately, minimizing the risk of errors and improving the continuity of care.

C. Visitor fall:
While a fall involving a visitor is an important incident, it doesn't typically require a structured communication tool like SBAR. Instead, it necessitates immediate response, assessment, and appropriate reporting within the hospital’s incident reporting system.

D. Needle stick injury to a nurse:
In the case of a needle stick injury, prompt reporting and proper follow-up are vital. While communication is crucial, it doesn't usually follow the structured format of SBAR. The nurse needs to report the incident to their supervisor or employee health, which would initiate appropriate protocols for testing, treatment, and documentation. Clear communication is necessary, but it doesn’t typically involve the use of the SBAR tool.