A nurse is reassessing a client before performing an intervention for a client who has hypertension. Which of the following are essential components of this skill? (Select all that apply.).

The nurse checks the client's identification bracelet and verifies allergies.

The nurse measures the client's blood pressure in both arms and compares with previous readings.

The nurse asks the client if they have taken any over-the-counter medications or herbal supplements.

The nurse reviews the most current evidence and guidelines for hypertension management.

The nurse explains the purpose, procedure, and potential side effects of the intervention to the client.

Answer and Explanation

Correct Answer : A,C,E

Choice A reason:

The nurse checks the client's identification bracelet and verifies allergies. This is an essential component of this skill because it ensures that the nurse is performing the intervention for the right client and avoids any potential adverse reactions or interactions due to allergies.

Choice B reason:

The nurse measures the client's blood pressure in both arms and compares with previous readings. This is not an essential component of this skill because it is not directly related to the intervention for hypertension. It is a part of the assessment process that should be done before planning the intervention.

Choice C reason:

The nurse asks the client if they have taken any over-the-counter medications or herbal supplements. This is an essential component of this skill because it helps the nurse to identify any possible factors that may affect the client's blood pressure or the effectiveness of the intervention. Some medications or supplements may interact with the prescribed drugs or alter the blood pressure level.

Choice D reason:

The nurse reviews the most current evidence and guidelines for hypertension management. This is not an essential component of this skill because it is not specific to the client's situation or needs. It is a part of the planning process that should be done before implementing the intervention.

Choice E reason:

The nurse explains the purpose, procedure, and potential side effects of the intervention to the client. This is an essential component of this skill because it respects the client's autonomy and informed consent. It also helps the client to understand what to expect and how to cope with any possible complications or discomforts.

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Correct Answer is B

Explanation

Choice A reason:

The client states that he has trouble sleeping at night. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice B reason:

The client has a blood pressure of 150/90 mm Hg. This is objective data because it is information that the nurse observes when conducting a physical assessment. Objective data is measurable and observable.

Choice C reason:

The client reports feeling anxious about his diagnosis. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

Choice D reason:

The client prefers not to discuss his personal issues. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.

A. Consult with other members of the health care team. B. Involve the client in decision making. C. Review current literature on diabetes management. D. Identify realistic and measurable outcomes.

Correct Answer is B

Explanation

Choice A reason:

Consulting with other members of the health care team is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While collaboration is important, the nurse should first involve the client in decision making to ensure that the plan of care is individualized, realistic and acceptable to the client.

Choice B reason:

Involve the client in decision making is the correct answer. This is the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. Involving the client in decision making promotes self-management, adherence and empowerment. The client is the best source of information about their preferences, goals and needs.

Choice C reason:

Reviewing current literature on diabetes management is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While evidence-based practice is essential, the nurse should first involve the client in decision making to ensure that the plan of care is based on the client's situation and values.

Choice D reason:

Identifying realistic and measurable outcomes is not the first action the nurse should take when developing a plan of care for a client who has diabetes mellitus. While outcome identification is a key step in the nursing process, the nurse should first involve the client in decision making to ensure that the outcomes are relevant and achievable for the client.

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A nurse is reassessing a client before performing an intervention for a client who has hypertension. Which of the following are essential components of this skill? (Select all that apply.).

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