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

Answer and Explanation

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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Correct Answer is B

Explanation

A. "You will be okay. Your surgeon will talk to you in the morning.": This statement is reassuring but does not encourage the patient to express their feelings or concerns. It is not considered therapeutic.
B. "Tell me how you care for your colostomy at home." This statement encourages the patient to share information and express concerns about their care, which is a therapeutic communication technique.
C. "I understand how you feel; the same thing happened to me last year." This shifts the focus to the nurse’s experience rather than the patient's feelings, which is nontherapeutic.
D. "Don't worry, you are in good hands." This is a reassuring statement that does not encourage the patient to express their feelings or concerns, making it nontherapeutic.

A. The nurse explains the benefits of smoking cessation B. The client starts to use nicotine gum as part of their plan to stop smoking C. The client uses a nicotine patch to assist in smoking cessation D. Encourage the client to share their feelings about smoking cessation

Correct Answer is D

Explanation

A. The nurse explains the benefits of smoking cessation: This approach uses the cognitive domain, focusing on knowledge and understanding.
B. The client starts to use nicotine gum as part of their plan to stop smoking: This action uses the psychomotor domain, involving physical tasks and skills.
C. The client uses a nicotine patch to assist in smoking cessation: This action also involves the psychomotor domain.
D. Encourage the client to share their feelings about smoking cessation: The affective domain involves emotions, attitudes, and feelings. Encouraging the client to share their feelings directly engages this domain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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