A nurse is reviewing the medical history of a client who is luted for surgery. Which of the following findings places the client at risk for a complication of incisional hematoma forming?

A) Planning:
The step of the nursing process where the nurse formulates goals to address an identified problem is planning. In this phase, the nurse develops a care plan by setting measurable and achievable goals based on the assessment data. These goals are designed to address the specific health problems identified during the assessment phase. The planning stage also involves determining appropriate interventions and establishing expected outcomes for the patient. It's critical to ensure that the goals are realistic and aligned with the patient’s needs and preferences.

B) Implementation:
Implementation refers to the actual carrying out of the nursing interventions and care plan that were developed during the planning phase. This is when the nurse takes action based on the goals set earlier, such as administering medications, teaching the patient, or performing specific procedures. While this phase is crucial for the success of the care plan, it does not involve the creation of goals, which is the focus of the planning phase.

C) Assessment:
Assessment is the first step in the nursing process. It involves gathering comprehensive information about the patient’s physical, psychological, social, and emotional status. The assessment phase is focused on identifying the patient’s needs, strengths, and problems. While it provides the foundation for formulating goals, it is not the phase where goals are set. Instead, the assessment phase is about collecting data to inform the planning process.
D) Evaluation:
Evaluation occurs after the implementation of interventions. During this phase, the nurse evaluates whether the patient’s goals have been met, partially met, or not met at all. The nurse examines the effectiveness of the care plan and determines if adjustments need to be made. This is not the phase where goals are set; rather, it is a reflective stage where the nurse assesses progress toward achieving the goals established in the planning phase.

A) Improved sexual function:
While ACE inhibitors like lisinopril may have a beneficial impact on overall health, improved sexual function is not a direct therapeutic effect of this medication. In fact, ACE inhibitors can sometimes cause side effects like sexual dysfunction in some individuals. Therefore, improved sexual function is not considered a therapeutic outcome for lisinopril.

B) Decreased blood pressure:
Lisinopril is an ACE (angiotensin-converting enzyme) inhibitor that works by blocking the conversion of angiotensin I to angiotensin II, which results in vasodilation and lowered blood pressure. Therefore, a decreased blood pressure is the expected and desired outcome when a client is on lisinopril. This is the primary therapeutic effect of the medication.

C) Increase of HDL cholesterol:
Lisinopril does not have a direct effect on increasing HDL (high-density lipoprotein) cholesterol. While ACE inhibitors may have some indirect cardiovascular benefits, such as improving endothelial function or reducing risk factors for heart disease, raising HDL cholesterol is not one of their specific effects. This outcome would not indicate a therapeutic effect of lisinopril.

D) Prevention of bipolar manic episodes:
Lisinopril is not used for the treatment or prevention of bipolar disorder or its manic episodes. While certain medications, such as mood stabilizers or antipsychotics, may be used in the management of bipolar disorder, lisinopril is not effective for this purpose. Therefore, preventing bipolar manic episodes is not a therapeutic outcome of lisinopril.