A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

Review the patient's medication history for any potential drug interactions.

Educate the patient about the potential side effects of the new medication.

Document the patient's baseline blood pressure before starting the medication.

Assess the patient's blood pressure to determine if the medication is effective.

Answer and Explanation

The Correct Answer is D

A. Reviewing medication history is important before starting a medication, not during the evaluation phase.

B. While education is important, the priority in the evaluation phase is determining whether the medication is working.

C. Baseline data is collected before treatment begins. The evaluation phase focuses on assessing the effectiveness of treatment.

D. The evaluation phase of the nursing process focuses on determining if interventions (such as medications) have achieved the desired outcomes.

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Correct Answer is D

Explanation

A. Forcing eye contact may be culturally insensitive.

B. No psychological evaluation is warranted based solely on this behavior.

C. Assuming depression without further assessment is inappropriate.

D. In some Asian cultures, avoiding eye contact can be a sign of respect rather than an indicator of depression or psychological distress.

A. Risk B. Actual C. Syndrome D. Wellness

Correct Answer is B

Explanation

A. A risk diagnosis applies when a problem has not yet occurred but is likely. This patient is already experiencing chest pain and hemodynamic instability, requiring an actual diagnosis.

B. The patient has current symptoms of chest pain, sweating, pallor, hypotension, and an irregular pulse, indicating a medical condition (possibly myocardial infarction). This justifies an actual diagnosis.

C. Syndrome diagnoses involve a cluster of related diagnoses, such as frail elderly syndrome. This patient’s case does not meet that definition.

D. Wellness diagnoses focus on improving health, not addressing an active medical crisis.

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A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Correct Answer is D

Explanation

A nurse assesses a patient who reports chest pain radiating down their arm. The nurse notes the patient is sweating and pale, BP 90/50 mmHg, pulse 120bpm, irregular. When developing the plan of care, what type of nursing diagnosis should the nurse use?

Correct Answer is B

Explanation

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Which of the following signs is most indicative of impaired skin integrity?

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