The nurse notes that an elderly client has a history of osteoporosis. What safety measure should the nurse prioritize for this client?

Choice A reason: Assessment is the first and most important phase of the nursing process, as it involves collecting and analyzing data about the patient's health status, needs, and preferences. The nurse should have assessed the patient's blood pressure before administering the antihypertensive medication, as it could have been contraindicated or required a dosage adjustment. By failing to do so, the nurse put the patient at risk of hypotension and its complications.

Choice B reason: Planning is the second phase of the nursing process, in which the nurse sets goals and outcomes for the patient's care and selects appropriate interventions. The nurse did not make an error in this phase, as the administration of the antihypertensive medication was part of the plan of care for the patient with hypertension.

Choice C reason: Diagnosis is the third phase of the nursing process, in which the nurse identifies the patient's actual or potential health problems based on the assessment data. The nurse did not make an error in this phase, as the diagnosis of hypertension was accurate and supported by the patient's history and vital signs.

Choice D reason: Evaluation is the fourth and final phase of the nursing process, in which the nurse measures the patient's progress and outcomes and modifies the plan of care as needed. The nurse did not make an error in this phase, as the re-checking of the blood pressure and the recognition of the patient's symptoms were part of the evaluation process. However, the nurse should have also notified the provider and implemented interventions to treat the hypotension.

Choice A reason: Identification is a defense mechanism where the person adopts the characteristics or behaviors of someone else, usually someone more powerful or successful, to cope with feelings of inadequacy or insecurity.

Choice B reason: Denial is a defense mechanism where the person refuses to accept or acknowledge the reality of a situation or a problem, to avoid dealing with the negative emotions or consequences.

Choice C reason: Displacement is a defense mechanism where the person transfers their feelings or impulses from the original source to a less threatening or more acceptable one, to reduce the anxiety or guilt.

Choice D reason: Rationalization is a defense mechanism where the person uses logical or plausible explanations to justify or excuse their actions or behaviors, to avoid facing the true motives or reasons.