Prior to administration of an antihypertensive medication, the nurse notes the client's heart rate is 50. The nurse then determines the blood pressure medication should be held. Which part of the nursing process is being fulfilled?
Assessment
Analysis
Planning
Evaluation
The Correct Answer is A
A. Assessment: Assessment involves collecting data about the client's condition. Noting the heart rate before administering medication is part of the assessment.
B. Analysis: Analysis involves interpreting the collected data to make decisions about the client's care. While the nurse is analyzing the data (the heart rate), this step follows the initial assessment.
C. Planning: Planning involves setting goals and deciding on interventions based on the assessment and analysis. Holding the medication could be considered part of planning but comes after assessing the heart rate.
D. Evaluation: Evaluation involves determining the effectiveness of interventions. This is not applicable in this situation.
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Related Questions
Correct Answer is C
Explanation
A. "I think you should talk with your family about your anger." This response shifts the focus to action without first exploring the client's feelings, which may not be therapeutic initially.
B. "You are probably very depressed, which is understandable with such a diagnosis." This response labels the client's emotions and may not be helpful in allowing the client to explore their feelings further.
C. "Tell me more about how you are feeling." This response uses therapeutic communication by encouraging the client to express feelings and concerns, providing emotional support and validation.
D. "Why haven't you shared your feelings with your family?" This response can sound accusatory and may not encourage open communication.
Correct Answer is C
Explanation
A. Develop short-term goals for the client in the teaching plan: Developing goals is part of the planning phase, not the assessment phase.
B. Show the client how to draw up the insulin in a syringe: This is part of the implementation phase, where the nurse provides instructions and demonstrations.
C. Assess the client’s readiness for learning: Assessing the client’s readiness to learn is part of the assessment phase, determining if the client is prepared and willing to learn the new skill.
D. Ask the client to demonstrate self-injection: This is part of the evaluation phase, where the nurse assesses the client’s ability to perform the skill taught.
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