Prior to administration of an antihypertensive medication, the nurse notes the client's heart rate is 50. The nurse then determines the blood pressure medication should be held. Which part of the nursing process is being fulfilled?
Assessment
Analysis
Planning
Evaluation
The Correct Answer is A
A. Assessment: Assessment involves collecting data about the client's condition. Noting the heart rate before administering medication is part of the assessment.
B. Analysis: Analysis involves interpreting the collected data to make decisions about the client's care. While the nurse is analyzing the data (the heart rate), this step follows the initial assessment.
C. Planning: Planning involves setting goals and deciding on interventions based on the assessment and analysis. Holding the medication could be considered part of planning but comes after assessing the heart rate.
D. Evaluation: Evaluation involves determining the effectiveness of interventions. This is not applicable in this situation.
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Related Questions
Correct Answer is C
Explanation
A. "The vital signs are stable." This statement belongs in the Assessment (A) step, as it provides information about the client’s current clinical condition.
B. "The client has a history of high blood pressure." This statement belongs in the Background (B) step, providing relevant medical history.
C. "The client is disoriented. Pupils are slow to respond to light." The S (Situation) step involves stating the immediate problem or reason for the communication. Describing the client's disorientation and pupil response directly addresses the current issue that prompted the call.
D. "The client should be seen by a neurologist." This statement belongs in the Recommendation (R) step, suggesting the next course of action.
Correct Answer is A
Explanation
A. Clarification: Clarification is a technique used to ensure that the nurse understands the client’s feelings and concerns correctly. By asking if the client is feeling anxious about the results, the nurse is clarifying the client’s statement.
B. Providing information: Providing information involves giving facts or details to the client, not seeking to understand their feelings.
C. Confrontation: Confrontation involves addressing discrepancies in the client’s statements or behaviors, which is not applicable in this situation.
D. Summarizing: Summarizing involves reviewing main points of the conversation, not clarifying feelings.
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