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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A healthcare proxy is a legal document that allows an individual to appoint someone to make medical decisions on their behalf if they are unable to do so themselves. This ensures that the individual’s healthcare preferences are followed even when they cannot communicate them. The proxy works closely with the healthcare team to ensure the patient’s wishes are respected.
Choice B rationale
Dictating funeral arrangements is not the primary purpose of a healthcare proxy. Funeral arrangements are typically handled through a will or other legal documents, not through a healthcare proxy.
Choice C rationale
Appointing a guardian for minor children is not the role of a healthcare proxy. This responsibility is usually designated through a will or other legal documents.
Choice D rationale
Managing the individual’s financial affairs is not the purpose of a healthcare proxy. Financial decisions are typically handled through a durable power of attorney for finances, not through a healthcare proxy.
Correct Answer is C
Explanation
Choice A rationale
Ensuring that the patient has been adequately monitored is important, but it is not the first step when considering the use of restraints. The nurse should first explore alternative interventions.
Choice B rationale
Proceeding with the application of restraints without considering alternatives can lead to unnecessary use of restraints, which can cause physical and psychological harm to the patient.
Choice C rationale
Exploring alternative interventions to address the patient’s behavior is the first step. Restraints should only be used as a last resort when other interventions have failed.
Choice D rationale
Obtaining verbal consent from the patient’s family is important, but it is not the first step. The nurse should first explore alternative interventions.
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