A nurse is reassessing a client before performing an intervention for a client who has hypertension. Which of the following are essential components of this skill? (Select all that apply.).
The nurse checks the client's identification bracelet and verifies allergies.
The nurse measures the client's blood pressure in both arms and compares with previous readings.
The nurse asks the client if they have taken any over-the-counter medications or herbal supplements.
The nurse reviews the most current evidence and guidelines for hypertension management.
The nurse explains the purpose, procedure, and potential side effects of the intervention to the client.
Correct Answer : A,C,E
Choice A reason:
The nurse checks the client's identification bracelet and verifies allergies. This is an essential component of this skill because it ensures that the nurse is performing the intervention for the right client and avoids any potential adverse reactions or interactions due to allergies.
Choice B reason:
The nurse measures the client's blood pressure in both arms and compares with previous readings. This is not an essential component of this skill because it is not directly related to the intervention for hypertension. It is a part of the assessment process that should be done before planning the intervention.
Choice C reason:
The nurse asks the client if they have taken any over-the-counter medications or herbal supplements. This is an essential component of this skill because it helps the nurse to identify any possible factors that may affect the client's blood pressure or the effectiveness of the intervention. Some medications or supplements may interact with the prescribed drugs or alter the blood pressure level.
Choice D reason:
The nurse reviews the most current evidence and guidelines for hypertension management. This is not an essential component of this skill because it is not specific to the client's situation or needs. It is a part of the planning process that should be done before implementing the intervention.
Choice E reason:
The nurse explains the purpose, procedure, and potential side effects of the intervention to the client. This is an essential component of this skill because it respects the client's autonomy and informed consent. It also helps the client to understand what to expect and how to cope with any possible complications or discomforts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Asking the client when they first noticed the symptoms is a relevant and appropriate question for a problem-focused assessment. It helps the nurse to determine the onset, duration, and frequency of the nausea and vomiting, which can provide clues to the possible causes and severity of the problem.
Choice B reason:
Asking the client about allergies or food intolerances is not directly related to the problem of nausea and vomiting. It might be useful to ask this question later in the assessment, but it is not the priority at this point. This question is more suitable for a comprehensive or initial assessment.
Choice C reason:
Asking the client to rate their pain on a scale of 0 to 10 is not relevant to the problem of nausea and vomiting. Pain is a different symptom that might or might not be associated with nausea and vomiting. This question is more suitable for a pain assessment.
Choice D reason:
Asking the client about their health goals is not related to the problem of nausea and vomiting. This question is more suitable for a wellness assessment or a health promotion intervention.
Correct Answer is A
Explanation
Choice A reason:
The PES format (problem, etiology, signs and symptoms) is the most comprehensive and accurate way to write a nursing diagnostic statement. It identifies the nursing problem, the cause or contributing factors, and the evidence or manifestations of the problem. For example, a possible PES statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern related to chronic airway obstruction as evidenced by dyspnea, tachypnea, and use of accessory muscles.
Choice B reason:
The PE format (problem, etiology) is a two-part diagnostic statement that omits the signs and symptoms of the problem. It is less specific and does not provide enough information to guide the nursing interventions and outcomes. For example, a possible PE statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern related to chronic airway obstruction. This statement does not indicate how the problem is manifested or measured.
Choice C reason:
The PS format (problem, signs and symptoms) is a two-part diagnostic statement that omits the etiology or cause of the problem. It is less precise and does not identify the factors that contribute to or influence the problem. For example, a possible PS statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Ineffective breathing pattern as evidenced by dyspnea, tachypnea, and use of accessory muscles. This statement does not indicate why the problem exists or what can be done to address it.
Choice D reason:
The ES format (etiology, signs and symptoms) is a two-part diagnostic statement that omits the problem or nursing diagnosis. It is incomplete and does not state what the actual or potential health issue is. For example, a possible ES statement for the client with COPD and shortness of breath and fatigue with minimal exertion is: Chronic airway obstruction as evidenced by dyspnea, tachypnea, and use of accessory muscles. This statement does not indicate what the nursing problem is or what the desired outcome is.
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