A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?
Establishing the priorities of client care.
Comparing the client's current laboratory values to previous results.
Asking the client about the presence of pain.
Reinforcing teaching about the client's diagnosis.
The Correct Answer is D
A. Establishing the priorities of client care is part of the planning phase, not the implementation phase.
B. Comparing laboratory values is an assessment activity that occurs before planning and implementing care.
C. Asking the client about pain is an assessment activity used to gather information rather than an implementation task.
D. Reinforcing teaching about the client's diagnosis is an action that occurs during the implementation phase, as it involves executing the care plan and providing direct client education.
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Correct Answer is B
Explanation
A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.
B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.
C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.
D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.
Correct Answer is D
Explanation
A. Identifying clients by room number instead of name does not adequately protect client confidentiality, as room numbers can still be linked to specific patients.
B. Logging assistive personnel into unit computers for documentation undermines security measures, as each user should have their unique login credentials.
C. Placing the client's name on the cover sheet when faxing protected health information violates confidentiality and can lead to unauthorized access to sensitive data.
D. Conducting change-of-shift reports in a designated staff-only area ensures that client information is not overheard by unauthorized individuals, maintaining confidentiality.