A nurse refers a client to a specialist for further evaluation. What level of prevention is this?

Choice A rationale
Planning is the phase of the nursing process where the nurse develops a plan of care based on the assessment data and identified nursing diagnoses. It involves setting goals and determining the appropriate interventions to achieve those goals. In this scenario, the nurse is not developing a plan but rather observing the effects of an intervention that has already been implemented.
Choice B rationale
Assessment is the initial phase of the nursing process where the nurse collects and analyzes data about the client’s health status. This includes gathering information through observation, interviews, physical examinations, and diagnostic tests. In this scenario, the nurse is not collecting new data but rather observing the outcome of a previously administered medication.
Choice C rationale
Evaluation is the phase of the nursing process where the nurse assesses the client’s response to the interventions and determines whether the goals of care have been met. In this scenario, the nurse is evaluating the effectiveness of the antihypertensive medication by noting the decrease in the client’s blood pressure. This assessment helps determine if the medication is achieving the desired therapeutic effect.
Choice D rationale
Analysis is the phase of the nursing process where the nurse interprets the assessment data to identify the client’s health problems and needs. It involves critical thinking and clinical judgment to determine the underlying causes of the client’s condition. In this scenario, the nurse is not analyzing data but rather evaluating the outcome of an intervention.

Choice A rationale
Contacting the patient’s family for approval before resuscitation is not appropriate when there is a Do Not Resuscitate (DNR) order. A DNR order is a legal document that indicates the patient’s wish not to undergo resuscitation in the event of cardiac or respiratory arrest.
Healthcare providers must respect this order and not seek additional approval from family members.
Choice B rationale
Respecting the order and refraining from initiating resuscitation is the correct action when there is a DNR order. This legal document reflects the patient’s decision to forgo resuscitation efforts, and healthcare providers are obligated to honor this decision to respect the patient’s autonomy and wishes.
Choice C rationale
Ignoring the order and proceeding with resuscitation is a violation of the patient’s rights and wishes. A DNR order must be followed to ensure that the patient’s preferences are respected, and disregarding it can lead to legal and ethical consequences.
Choice D rationale
Implementing the order only if the patient is in the ICU is incorrect. A DNR order applies in all healthcare settings, not just the ICU. Healthcare providers must follow the DNR order regardless of the patient’s location within the healthcare facility.