A nurse is collecting data on a patient who is being admitted ...

[Pineappleeh]

A nurse is collecting data on a patient who is being admitted into hospice care. The nurse collects data from both the patient and the family so that a clear picture of the patient status is obtained.
 
  The nurse is currently involved in which step of the nursing process? a. Assessment
  b. Implementation
  c. Evaluation
  d. Diagnosing

Question 2

The patient has just returned to the postsurgical unit after undergoing surgery to remove a lung tumor. During one of the postoperative vital sign checks, the nurse notes that the patient's sys-tolic blood pressure had dropped by 30 points.
 
  In addition to the drop in systolic blood pressure, the patient's skin is pale and clammy. The nurse should do which of the following? a. Report the findings to the health care pro-vider immediately.
  b. Understand that the patient's arteries are constricting, causing pallor.
  c. Wait to see if the blood pressure increases in 30 minutes.
  d. Nothing; this is a normal occurrence fol-lowing a thoracic surgery.

[strudel15]

Answer to Question 1

A
Assessment is the deliberate and systematic collection of data about a patient. The data will re-veal a patient's current and past health status, functional status, and present and past coping pat-terns. A nursing diagnosis is a clinical judgment about individual, family, or community res-ponses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Implementation is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care. Evaluation is crucial to deciding whether, after interventions have been delivered, a patient's condition or well-being improves.

Answer to Question 2

A
Signs and symptoms associated with hypotension include pallor, skin mottling, clamminess, confusion, dizziness, chest pain, increased heart rate, and decreased urine output. Hypotension is usually life threatening and needs to be reported immediately to the patient's health care provider. Doing nothing can lead to the patient's death. Hypotension occurs when arteries dilate; the peri-pheral vascular resistance decreases, the circulating blood volume decreases, or the heart fails to provide adequate cardiac output.