A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process?
Assessment
Planning
Diagnosis
Evaluation
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Cataracts are a condition that causes the lens of the eye to become cloudy and opaque. They can cause symptoms such as blurred vision, glare, halos, and reduced color perception. They do not affect the shape of the lines on the Amsler grid or the center of vision.
Choice B reason: Glaucoma is a condition that causes increased pressure in the eye and damage to the optic nerve. It can cause symptoms such as gradual loss of peripheral vision, tunnel vision, and eye pain. It does not affect the shape of the lines on the Amsler grid or the center of vision.
Choice C reason: Macular degeneration is a condition that affects the macula, the central part of the retina. It can cause symptoms such as distorted vision, dark spots, and loss of central vision. It can affect the shape of the lines on the Amsler grid and the center of vision.
Choice D reason: Retinal detachment is a condition that occurs when the retina separates from the back of the eye. It can cause symptoms such as flashes, floaters, and a curtain-like vision loss. It does not affect the shape of the lines on the Amsler grid or the center of vision.
Correct Answer is A
Explanation
Choice A reason: Weight-bearing exercise, such as walking, jogging, or dancing, helps to strengthen the bones and prevent osteoporosis. It also improves muscle strength, balance, and coordination, which can reduce the risk of falls and fractures.
Choice B reason: Having a bone density scan every year is not necessary for a young adult client who has a family history of osteoporosis. A bone density scan is a test that measures the amount of calcium and other minerals in the bones. It is usually recommended for women over 65 years old, men over 70 years old, or people who have risk factors for osteoporosis, such as low body weight, smoking, or steroid use.
Choice C reason: Taking a magnesium supplement every day is not a proven way to prevent osteoporosis. Magnesium is a mineral that is involved in bone formation and metabolism, but there is not enough evidence to support its role in preventing or treating osteoporosis. A balanced diet that includes foods rich in calcium, vitamin D, and other nutrients is more effective for bone health.
Choice D reason: Drinking a cup of coffee every morning is not a good idea for a young adult client who has a family history of osteoporosis. Coffee contains caffeine, which can interfere with the absorption of calcium and increase the excretion of calcium in the urine. This can lead to lower bone density and higher risk of osteoporosis. Moderate coffee consumption (one or two cups per day) may not have a significant effect on bone health, but excessive coffee intake (more than four cups per day) should be avoided.
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