Author Question: Which of the following statements best reflects the nurse's understanding of the function of client ... (Read 73 times)

james0929 · **on:** Jul 22, 2018

Which of the following statements best reflects the nurse's understanding of the function of client reassessment?

a. The client's blood pressure is lower this morning than it was yesterday morning.
b. 30 minutes after receiving his pain medication, the client evaluated his pain at 3 out of 10.
c. Turning the client every 2 hours has helped in the healing of the pressure ulcer on his coccyx.
d. Since the client has been ambulating to the bedroom without difficulty, I'll walk with him to the dayroom after dinner.

Question 2

A number of different types of nursing interventions may be incorporated into the plan of care. Which of the following interventions is an example of a specific lifesaving measure that the nurse may implement?

a. Restraining a violent client
b. Administering analgesics
c. Initiating stress-reduction therapy
d. Teaching the client how to take his or her pulse

Athena23 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
When reassessment results in the collection of new data that identify a new client need, the care plan is modified. Modification of a care plan also occurs when a client's health care need shows improvement or is resolved.
The option The client's blood pressure is lower this morning than it was yesterday morning reflects recognition of a change in the client's condition but does not reflect an alteration in the care plan.
The option 30 minutes after receiving his pain medication, the client evaluated his pain at 3 out of 10 reflects recognition of a change in the client's condition but does not reflect an alteration in the care plan.
The option Turning the client every 2 hours has helped in the healing of the pressure ulcer on his coccyx reflects recognition of a change in the client's condition but does not reflect an alteration in the care plan.

Answer to Question 2

A
Restraining a violent client is an example of a lifesaving measure to protect the client. The pur-pose of a lifesaving measure is to restore physiological or psychological equilibrium.
Administering analgesics is an example of a physical care technique. It is not a lifesaving meas-ure.
Initiating stress-reduction therapy is an example of a counselling technique.
Teaching the client how to take his or her pulse is an example of the nursing intervention of teaching. The focus is for the client to obtain new knowledge or psychomotor skills.