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
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Correct Answer is B
Explanation
Choice A rationale
Ensuring the client can independently manage their care is important, but it does not directly address potential barriers that could affect adherence to the discharge plan. Identifying barriers is crucial to ensure the client can follow through with the plan safely and effectively.
Choice B rationale
Identifying potential barriers to adherence is essential for client safety during the discharge process. This includes assessing the client’s understanding of their care plan, their ability to access medications, and any social or financial obstacles that may hinder their adherence. By addressing these barriers, the nurse can help ensure the client follows the discharge plan and reduces the risk of complications or readmissions.
Choice C rationale
Avoiding discussion of dietary restrictions is incorrect because dietary restrictions are often a critical component of a client’s care plan. Discussing and ensuring the client understands these restrictions is vital for their safety and health management post-discharge.
Choice D rationale
Providing information quickly to expedite discharge is not a safe practice. It is important to ensure the client fully understands their discharge instructions, which requires taking the time to explain and confirm comprehension. Rushing through this process can lead to misunderstandings and potential harm.
Correct Answer is A
Explanation
Choice A rationale
“I can see this is very difficult for you.”. This response is appropriate as it acknowledges the client’s emotions and provides validation. It demonstrates empathy and encourages the client to express their feelings, which is essential in therapeutic communication.
Choice B rationale
“Please don’t cry, it’s not good for you.”. This response is inappropriate as it dismisses the client’s emotions and may make them feel invalidated. Crying is a natural response to emotional distress, and the nurse should support the client in expressing their feelings.
Choice C rationale
“Why are you crying?” This response is also inappropriate as it may come across as judgmental or dismissive. It does not provide the support and empathy the client needs during a difficult moment.
Choice D rationale
“Let’s move on to a different topic to distract you.”. This response is not appropriate as it avoids addressing the client’s emotions and may make the client feel that their feelings are not important. The nurse should focus on supporting the client through their emotional experience.
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