After administration of an antihypertensive medication, the nurse notes the client’s blood pressure decreases by 10 points. Which part of the nursing process is being fulfilled?
Planning.
Assessment.
Evaluation.
Analysis.
The Correct Answer is C
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Recognizing cultural preferences is important, but it does not demonstrate the use of the Self- Care Model. The Self-Care Model focuses on promoting autonomy and self-care.
Choice B rationale
Performing all tasks independently does not align with the Self-Care Model, which emphasizes promoting the client’s ability to care for themselves.
Choice C rationale
Calculating intake and output accurately is important, but it does not demonstrate the use of the Self-Care Model. The Self-Care Model focuses on promoting autonomy and self-care.
Choice D rationale
Encouraging autonomy by allowing the client to feed themselves is the correct answer. This action aligns with the Self-Care Model, which emphasizes promoting the client’s ability to care for themselves.
Correct Answer is A
Explanation
Choice A rationale
The assessment component of the SBAR report includes the nurse’s evaluation of the patient’s condition, such as pain level, blood pressure, and heart rate. This information is critical for the provider to understand the patient’s current status and make informed decisions.
Choice B rationale
The situation component of the SBAR report provides a brief overview of the patient’s current situation, such as the reason for the call or the immediate concern. It does not include detailed assessment data.
Choice C rationale
The recommendation component of the SBAR report includes the nurse’s suggestions for the next steps or actions to be taken. It does not include the patient’s assessment data.
Choice D rationale
The background component of the SBAR report provides relevant medical history and context for the patient’s current condition. It does not include the detailed assessment data.
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