Author Question: You find a patient on the floor at shift change. She is awake and alert. She is confused now and was ... (Read 131 times)

lb_gilbert · **on:** Jul 19, 2018

You find a patient on the floor at shift change. She is awake and alert. She is confused now and was not confused prior to the being found on the floor. What is your first step in the nursing process in this situation?

A.
Leave the patient to get help.
B.
Gather more information by making observations about the patient.
C.
Call the patient's MD from your cell phone.
D.
Help the patient get up and then document your findings in the chart.

Question 2

A patient is admitted into a mental health unit screaming and kicking. Although this patient is acting out, she also is verbalizing that her leg is hurting. What type of planning would benefit this patient the most?

A.
Short-term goal
B.
Long-term goal
C.
Intervention
D.
Evaluation

Ahnyah · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

ANS: B
Being the first person on scene, you need to find out as much information as possible to report to the charge nurse as part of data collection. Never leave the patient alone until you are sure the patient is secure.

Answer to Question 2

ANS: A
The plan should be to provide the patient with short-term care first. If the pain in her leg is reduced, the patient will possibly stop screaming. Planning needs to occur before intervention.