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 C
Explanation
Choice A rationale
Providing written handouts for reference can be helpful, but it is not the most effective strategy for fall prevention education among older adults. Interactive methods are generally more engaging and effective.
Choice B rationale
Using complex medical terminology to explain concepts is not effective for older adults. It can lead to confusion and misunderstanding, reducing the effectiveness of the education.
Choice C rationale
Using interactive demonstrations and group discussions is the most effective strategy for teaching fall prevention to older adults. These methods engage the audience, making the information more relatable and easier to understand.
Choice D rationale
Speaking quickly to maintain attention is not effective for older adults. It can lead to information being missed or misunderstood. Clear, slow, and interactive communication is more effective.
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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