A nurse is modifying a patient's care plan after evaluation of ...

[mynx]

A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks?
 
  1. Revise nursing diagnosis.
  2. Reassess blood pressure reading.
  3. Retake blood pressure after medication.
  4. Administer new blood pressure medication.
  5. Change goal to blood pressure less than 140/90.
  a. 1, 5, 2, 4, 3
  b. 2, 1, 5, 4, 3
  c. 4, 3, 1, 5, 2
  d. 5, 4, 5, 1, 2

Question 2

A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion?
 
  a. Patient wanders halls at night.
  b. Patient's side rails are up with bed alarm activated.
  c. Patient denies pain while ambulating with assistance.
  d. Patient correctly states names of family members in the room.

[memslove]

Answer to Question 1

ANS: B
If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. After reassessment, determine which nursing diagnoses are accurate for the situation; revise as needed. When revising a care plan, review the goals and expected outcomes for necessary changes after the diagnosis. Then evaluate and revise interventions as needed.

Answer to Question 2

ANS: D
The goal for this patient would address a decrease or absence of confusion. Thus, one possible sign that a patient's confusion is improving is seen when a patient can correctly state the names of family members in the room. You examine the results of care by using evaluative measures that relate to goals and expected outcomes. Keeping the side rails up and using a bed alarm are interventions to promote patient safety and prevent falls. The patient's denying pain indicates positive progress toward resolving pain. The patient's wandering the halls is a sign of confusion.