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 C

Explanation

A. Collaborative problem. This is incorrect because a collaborative problem involves complications requiring both medical and nursing interventions. The statement is a nursing diagnosis, not a collaborative problem.

B. Nursing diagnosis. This is incorrect because "Impaired Physical Mobility" is an appropriate NANDA-I approved nursing diagnosis.

C. Etiology. This is correct because "tibial fracture" is a medical diagnosis, and nursing diagnoses should not include medical conditions as the etiology. Instead, the etiology should focus on the patient’s response, such as "pain and muscle weakness" related to the fracture.

D. Defining characteristic. This is incorrect because "patient's inability to ambulate" is an appropriate defining characteristic that supports the diagnosis of impaired mobility.

A. Ask the patient to make eye contact to determine her affect. B. Notify the health care provider to recommend a psychological evaluation. C. Continue with the interview and document that the patient is depressed. D. Consider cultural differences during this assessment.

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.

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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

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Correct Answer is C

Explanation

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

Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?

The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?

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?

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?

When using the PIE format for documentation, which of the following elements should the nurse include under 'P?

A nursing is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide report to the oncoming nurse?

The nurse begins discharge planning for an older adult with left-side weakness. Which action is most important in ensuring that the discharge plan is successful?

A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?