Answer to Question 1
ANS: C
After identifying a patient's nursing diagnoses and collaborative problems, a nurse prioritizes the diagnoses, sets patient-centered goals and expected outcomes, and chooses nursing interventions appropriate for each diagnosis. This is the third step of the nursing process, planning. The assessment phase of the nursing process involves gathering data. The implementation phase involves carrying out appropriate nursing interventions. During the evaluation phase, the nurse assesses the achievement of goals and effectiveness of interventions.
Answer to Question 2
ANS: B
The nurse needs to first ensure that the symptoms support the diagnosis. By definition, diarrhea means that a patient is having frequent stools; therefore, asking about the number of bowel movements is most appropriate. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate. Asking the patient if he can make it to the bathroom will help to establish a diagnosis of incontinence, not diarrhea. The question is asking for the most appropriate statement to establish the diagnosis of Diarrhea.
(A) Scratch test; patient is exposed to allergens through a light scratch on the skin; (B) Positive
Comparison of the teaching and nursing
Patient teaching: male genetalia assessment
Jaundice seen in the eyes and the skin of a patient with hepatitis A.
Toxoplasma gondii in the heart of an HIV patient.
Nurse using a stethoscope