A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

Review the patient's medication history for any potential drug interactions.

Educate the patient about the potential side effects of the new medication.

Document the patient's baseline blood pressure before starting the medication.

Assess the patient's blood pressure to determine if the medication is effective.

Answer and Explanation

The Correct Answer is D

A. Reviewing medication history is important before starting a medication, not during the evaluation phase.

B. While education is important, the priority in the evaluation phase is determining whether the medication is working.

C. Baseline data is collected before treatment begins. The evaluation phase focuses on assessing the effectiveness of treatment.

D. The evaluation phase of the nursing process focuses on determining if interventions (such as medications) have achieved the desired outcomes.

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Correct Answer is C

Explanation

A. While teamwork is crucial, patient input should come first to ensure the plan aligns with their needs and capabilities.

B. Family involvement is beneficial, but the patient should have the primary role in decision-making.

C. Effective discharge planning is patient-centered, ensuring that goals align with their preferences, abilities, and resources.

D. Although discharge planning should begin at admission, the most important factor for success is patient involvement.

A. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight B. Caregiver Role Strain, related to depression, as evidenced by constant crying C. Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area D. Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain

Correct Answer is C

Explanation

A. Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight. This is incorrect because "Inability to Ingest Food" is not a NANDA-I approved nursing diagnosis.

B. Caregiver Role Strain, related to depression, as evidenced by constant crying. This is incorrect because "depression" is a medical diagnosis and not an appropriate etiology for a nursing diagnosis. Nursing diagnoses should be based on nursing-related causes.

C. Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area. This is correct because it follows the correct NANDA-I format:

Diagnosis: Impaired Skin Integrity

Etiology (related to): Physical immobility

Defining characteristics (as evidenced by): Skin tear over the sacral area

D. Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain. This is incorrect because "Bowel Obstruction" is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on patient responses, such as "Risk for Impaired Bowel Elimination."

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A 65-year-old male patient with hypertension was recently started on a new antihypertensive medication. During the evaluation phase of the nursing process, which action should the nurse prioritize?

Nursing Test Bank

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