A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
Patient will have one soft, formed bowel movement by end of shift.
Patient will not take any pain medications this shift.
Patient will walk unassisted to bathroom by the end of shift.
Patient will be offered laxatives or stool softeners this shift.
The Correct Answer is A
A. This outcome is specific, measurable, and directly addresses the goal of managing constipation by aiming for a bowel movement.
B. Discontinuing pain medication abruptly may be unrealistic and can cause distress for the patient.
C. Ambulation may help with constipation but does not directly measure or ensure bowel movement.
D. Offering laxatives or stool softeners is an intervention rather than a measurable patient outcome.
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Correct Answer is D
Explanation
A. Grief evaluation refers to assessing the grief process rather than actively engaging in supportive dialogue, which is not the primary focus of the nurse's action.
B. Pain-management techniques would not apply directly to this context, as the discussion centers on emotional support rather than physical pain.
C. Palliative care encompasses a broader approach to managing patients with serious illnesses but does not specifically address the emotional support provided in this situation.
D. The nurse's action of discussing the child's life and death helps the parents express their grief and memories, thereby facilitating normal mourning, making this the most appropriate principle demonstrated.
Correct Answer is C
Explanation
A. Identifying immobility hazards requires clinical judgment and assessment skills that are beyond the scope of nursing assistive personnel.
B. Determining the level of comfort is a subjective assessment that should be done by a nurse to ensure accurate interpretation of the patient’s condition.
C. Changing the patient's position can be safely delegated to nursing assistive personnel, as it is a straightforward task that does not require advanced clinical judgment.
D. Assessing circulation involves evaluating the patient's vital signs and other parameters, which should be performed by a nurse to ensure comprehensive care and assessment.