Order of planning patient care assessment

Order of planning patient care assessment
A home care nurse is visiting an older adult who
experienced a brain attack 2 years ago and now has a
sacral pressure ulcer. The nurse identifies that the
patient and spouse both appear unkempt and the
spouse appears tired and irritated. The patient is very
quiet and avoids eye contact. Which nursing action is
most appropriate?
1. Explore with the patient and spouse their concerns.
2. Assess the patient for signs of physical abuse and
neglect.
3. Discuss with the patient and spouse additional
resources to help with the patient’s care.
4. Assess the patient’s pressure ulcer and report find-
ings to the primary health-care provider.
2. A patient is admitted to a home health-care program
for palliative care. When completing the admission
interview and nursing assessment the patient empath-
ically states, “I want no intervention to extend my life
other than keeping me comfortable.” When talking
with family members they want the patient to con-
tinue chemotherapy. What should the nurse do?
1. Protect the patient’s right to self-determination.
2. Initiate a referral to a psychiatric nurse practitioner.
3. Ask the patient to reconsider chemotherapy for the
sake of the family.
4. Refer family members to the primary health-care
provider to resolve this issue.
3. A nurse is planning patient care based on moral and
ethical principles. Which nursing statement demon-
strates an effort to implement the principle of fidelity?
1. “Let’s talk about foods that are healthy and that you
should include in your daily diet.”
2. “I know that you are out of work, so I have arranged
for you to get follow-up care at our out-patient clinic.”
3. “You said that your son wants you to have this sur-
gery. What is important is what you believe is best
for you.”
4. “It’s been half an hour and I am back as I promised
to ensure that the pain medication I gave you is
providing relief.