Author Question: Which of the following nursing activities is most reflective of the evaluation phase of the nursing ... (Read 123 times)

genevieve1028 · **on:** Jul 23, 2018

Which of the following nursing activities is most reflective of the evaluation phase of the nursing process?

a. Administering pain medication prior to changing a complex wound dressing
b. Obtaining patient's blood pressure 30 minutes after administering blood pressure medication
c. Reporting that there have been three patient falls in the past month on the nursing unit
d. Teaching the patient how to perform daily Accu-Cheks for blood sugar readings

Question 2

What is wrong with the following diagnostic statement? Impaired Physical Mobility related to laziness and not having appropriate shoes. The statement is:

a. Judgmental
b. Too complex
c. Legally questionable
d. Without supportive data

Liddy · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

B
Evaluation is the final step of the nursing process. It is a planned, ongoing, systematic activity in which a nurse will make judgments about patient progress toward desired health outcomes, effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting. Evaluation data are collected after interventions are performed to determine whether patient goals were achieved. In this item, obtaining a patient's blood pressure after administering blood pressure medications evaluates the patient's response to the medication. Administering pain medication prior to performing a dressing change is an intervention, as is teaching a patient to perform an Accu-Chek. Reporting patient falls is part of the assessment process.

Answer to Question 2

A
Lazy implies criticism of the client and therefore is judgmental. There need to be several (certainly more than two) etiological factors for the statement to be complex. There is no blame implied or harm resulting, so the statement is not legally questionable. There is no minimum amount of supportive data for a diagnosis and the stated etiology related to the nursing diagnosis. No supportive data are given in the stem of the question, so you could not choose lack of data as the best answer because all the options lack data as far as you can tell from the information given in the question. In addition, it is not necessary to include supportive data in the diagnostic statement (although some do prefer to use AMB and include defining characteristics).