The patient is admitted with a diagnosis of chronic anxiety. Which action is most appropriate for the nurse to take when providing holistic care?
Realizing that the patient's only goal is relief of the anxiety.
Looking at how worry influences the patient's ability to function.
Helping the patient realize that there is little hope of relief from anxiety.
Focusing on finding quick remedies for the anxiety.
The Correct Answer is B
A. While anxiety relief is important, holistic care encompasses the patient's overall well-being and not just the alleviation of symptoms.
B. Understanding how anxiety impacts the patient's daily functioning allows for a more comprehensive approach to care, addressing both psychological and practical concerns.
C. It is inappropriate to suggest to the patient that there is little hope for relief, as this can negatively affect their mental health.
D. Focusing solely on quick fixes does not address the underlying issues of chronic anxiety and may not lead to long-term improvements.
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Correct Answer is D
Explanation
A. Assessment has already been completed as the initial step, involving data collection.
B. Diagnosis is also completed, involving analysis and identification of the patient’s health problems.
C. Implementation occurs after planning, when nursing interventions are executed.
D. Planning is the appropriate next step, involving the creation of specific, measurable goals and interventions based on the identified nursing diagnoses.
Correct Answer is D
Explanation
A. Vision is not commonly affected by vancomycin, so it is not a priority to assess.
B. Heart tones are not directly impacted by vancomycin and do not require immediate monitoring unless there are specific cardiovascular concerns.
C. Bowel sounds are not directly influenced by vancomycin and do not need to be prioritized in this case.
D. Vancomycin is known to be ototoxic, especially in high doses or with prolonged use, so monitoring for signs of hearing loss or tinnitus is essential to prevent potential irreversible damage.