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
Poor balance and muscle weakness are significant risk factors for falls among older adults. These conditions can make it difficult for individuals to maintain stability and recover from a loss of balance, increasing the likelihood of falls.
Choice B rationale
Vision impairment is a well-known risk factor for falls. Poor vision can make it difficult for individuals to see obstacles and navigate their environment safely, leading to an increased risk of falls.
Choice C rationale
Medications that cause dizziness are a common risk factor for falls. Many medications, including those for blood pressure, pain, and anxiety, can have side effects that affect balance and coordination, increasing the risk of falls.
Choice D rationale
Regular physical activity is not a risk factor for falls. In fact, regular exercise can improve strength, balance, and coordination, reducing the risk of falls. Physical activity is often recommended as a preventive measure to help older adults maintain their mobility and independence.
Correct Answer is B
Explanation
Choice A rationale
Encouraging the use of sedatives to promote better sleep is incorrect. Sedatives can increase the risk of falls in older adults due to their side effects, such as dizziness and impaired coordination. It is important to use non-pharmacological methods to promote sleep and reduce fall risk.
Choice B rationale
Removing tripping hazards from the home is a key action to reduce falls in older adults. This includes securing loose rugs, keeping walkways clear, and ensuring that cords and other objects are not in areas where they could cause a trip. By creating a safer environment, the risk of falls is significantly reduced.
Choice C rationale
Ensuring proper lighting in all areas of the home is also important for fall prevention. Adequate lighting helps older adults see potential hazards and navigate their environment safely. This includes using nightlights in hallways and bathrooms and ensuring that all rooms are well-lit.
Choice D rationale
Avoiding the use of diuretics at night can help reduce the need for nighttime bathroom trips, which can be a fall risk. However, this choice alone is not as comprehensive as removing tripping hazards, which addresses multiple potential fall risks in the home.
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