Author Question: A patient with a congenital heart defect is admitted for further testing. The nurse observes the ... (Read 72 times)

Lisaclaire · **on:** Jul 23, 2018

A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process?

a. Assessment
b. Planning
c. Implementation
d. Evaluation

Question 2

The nurse is admitting a patient experiencing chest discomfort and shortness of breath. The patient also has a history of stroke. The nurse documents the nursing diagnosis Risk for stroke related to history of stroke. The risk factor for this patient is

a. stroke.
b. history of stroke.
c. chest discomfort.
d. shortness of breath.

KKcool · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: A
During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Answer to Question 2

ANS: B
A two-part risk nursing diagnostic statement contains only (1) the patient's identified need or problem (i.e., NANDA-I nursing diagnostic label) and (2) factors indicating vulnerability (i.e., risk factors). The risk factor is the history of stroke. The chest discomfort and shortness of breath are symptoms of the current problems and would not be documented as potential or risk issues. Stroke would be the identified potential problem.