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. Speak loudly and use simple words: Speaking loudly may be perceived as shouting and can increase agitation. Using simple words is appropriate, but volume should be normal and calm.
B. Address the client by name and reorient client: Addressing the client by name and reorienting him is effective because it respects his dignity and helps him understand his current situation, reducing confusion and agitation. This approach is clear, respectful, and supportive.
C. Challenge the client to refocus his attention when he becomes agitated: Challenging the client can be confrontational and may escalate agitation. It is better to use a calm, reassuring approach.
D. Ask the client a series of questions without allowing time for the client to answer: This can overwhelm and frustrate the client, leading to increased agitation.

A. dizziness B. facial droop C. numbness D. Fatigue

Correct Answer is B

Explanation

A. Dizziness: Dizziness is a subjective symptom reported by the client.
B. Facial droop: Objective data is information that can be directly observed or measured by the healthcare professional. It's independent of the client's interpretation or feelings. A facial droop is an observable and measurable sign, making it objective data.
C. Numbness: Numbness is a subjective symptom reported by the client.
D. Fatigue: Fatigue is a subjective symptom reported by the client.

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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

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