Author Question: A nurse is completing a plan of care for a client. The statement client will be able to walk 10 ... (Read 69 times)

CharlieWard · **on:** Jul 23, 2018

A nurse is completing a plan of care for a client. The statement client will be able to walk 10 feet, twice a day without shortness of breath is which part of the nursing process (in comparison to the decision-making process)?

1. Assess
2. Diagnose
3. Plan
4. Evaluate

Question 2

A client comes into the clinic with complaints of extreme low back pain after helping to move a heavy object. The client is pale and diaphoretic and walks bent at the waist.

Before taking vital signs, the nurse projects that the blood pressure as well as heart rate will be elevated. This is an example of which of the following?
1. Fact
2. Inference
3. Judgment
4. Opinion

bob · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 3
Rationale: The planning portion of the nursing process involves setting criteria (walking 10 feet twice a day), weighting the criteria, and seeking/examining alternatives when compared to the decision-making process. Assessment is the same as identifying the purpose. Diagnosing is putting a label on the problem. Evaluating is reviewing the outcome.

Answer to Question 2

Correct Answer: 2
Rationale: Inferences are conclusions drawn from facts, going beyond facts to make a statement about something that is not currently known. In this case, acute, severe pain will most likely cause the blood pressure as well as pulse rate to be elevated as the body's response to the painful experience. Fact can be verified through investigation. In this case, fact would be the elevated pulse and blood pressure readings. Judgment is evaluating facts and information that reflect values or other criteria; it is a type of opinion. Because the nurse understands the pathophysiology of pain, thinking about changes in vital signs is more than a judgmentit is an inference. Opinions are beliefs formed over time and include judgments that may fit facts or be in error.