Question

A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process?

A. Assessment
B. Planning
C. Implementation
D. Evaluation

Answer 1

The nurse is demonstrating the Assessment phase of the nursing process by observing a patient's symptoms, an important step in detecting conditions like congenital heart defects.

Step-by-step explanation:

The nurse observing a patient with increased shortness of breath and restlessness is demonstrating the Assessment phase of the nursing process. This initial phase involves gathering information about the patient's health status, which then informs subsequent decisions and care planning.

Auscultation using a stethoscope is a common assessment technique for detecting heart conditions such as congenital heart defects. Through auscultation, a nurse can listen for abnormal heart sounds that may correspond with such defects. Abnormalities in breathing and patient behavior, such as increased shortness of breath and restlessness, can also indicate the need for further diagnostics like imaging to confirm or rule out the presence of conditions like septal defects which are common and usually first detected by auscultation.