Nursing Process, Prioritization, delegation, and assignment and critical care Flashcards
A client was admitted to a medical–surgical unit at 0900. The client reported experiencing abdominal pain during the night, which was unrelieved after taking oral pain medication prescribed by the provider. A family member transported the client to the emergency department (ED). The client received IV morphine in the ED and was admitted to the medical–surgical unit for further workup of the abdominal pain. After completing an initial admission assessment, the nurse left the room to discuss the client’s plan of care with the attending provider.
Upon returning to the client’s room several minutes later, the nurse observes that a visitor is with the client. The visitor pulls the nurse aside, stating, “There is something wrong with my friend. She keeps referring to me as her brother, but her brother passed away many years ago. She also thinks that I have come to visit her at her home.” How should the nurse categorize the client’s needs at this time using urgent versus nonurgent categorization? (Enter your response and submit to compare to an expert’s response.)
The nurse should categorize a change in neurologic status as an urgent need. Clients who are experiencing respiratory difficulty, chest pain, or a change in neurologic status are prioritized as urgent. The nurse should collect further client data and report this finding.
Due to increased shortness of breath, an older adult client was brought to an urgent-care clinic by their adult child. The child reported that the client had become increasingly short of breath over the previous two days. The client has a history of anxiety, which is managed with PRN lorazepam, and has fallen two times within the past week. Their child reports that the client has been upset recently at the loss of their best friend, whom they had known for many years.
The client’s vital signs are as follows: BP 130/84 mm Hg, pulse 88/min, respiratory rate 24/min, oxygen saturation 90% on room air. The client’s adult child asks the nurse what their plan of action is in caring for the client. What should the nurse identify as this client’s priority problem? (Enter your response and submit to compare to an expert’s response.)
When using Maslow’s hierarchy of needs, the nurse should identify the client’s physiological needs as the priority. This client is experiencing increased shortness of breath, and his respiratory rate and oxygen saturation levels are above the expected range. The nurse should administer oxygen to the client.
What are the FIVE steps of the nursing process?
1: Assess the patient, family, caregivers, group, or community.
2. Consider all the data you have collected and arrive at a diagnosis (can be an actual problem or a problem you have determined the patient is at risk for) NOTE, A NURSING DIAGNOSIS IS NOT THE SAME AS A MEDICAL DIAGNOSIS.
3: Plan your care, which includes prioritization of the problems with goal setting for each one;
4: Perform the interventions that based on your clinical judgment will achieve the goals of care.
5. Evaluate the patient, family, group, or community’s response to your interventions.
