The nurse is developing a teaching plan for an elderly patient who will begin taking an antihypertensive drug that causes dizziness and orthostatic hypotension. Which nursing diagnosis is appropriate for this patient?
Deficient knowledge related to drug side effects
Ineffective health maintenance related to age
Readiness for enhanced knowledge related to medication side effects
Risk for injury related to side effects of the medication
The Correct Answer is D
A. Deficient knowledge may be a concern, but the primary focus here is on the safety risk associated with the side effects of the medication, particularly dizziness and orthostatic hypotension, which increase the risk of falls or injury.
B. Ineffective health maintenance is not specific to the medication side effects and does not directly address the patient's safety risk due to the medication.
C. Readiness for enhanced knowledge is more appropriate when the patient is already familiar with their condition and medication and is ready to learn more. This is not the case here, as the focus is on preventing harm from side effects.
D. Risk for injury is the most appropriate nursing diagnosis. Dizziness and orthostatic hypotension increase the risk of falls, which can lead to injury, making this the most relevant concern in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a) Assessment involves gathering and analyzing data about the patient, such as their living situation, memory issues, and medication regimen, but it does not include developing a strategy to address these concerns.
b) Planning is the phase where the nurse develops interventions to help the patient manage their medications safely. By creating a medication chart and involving a family member, the nurse is ensuring adherence to the prescribed regimen.
c) Evaluation occurs after implementation to assess the effectiveness of the plan, such as checking if the patient is taking the medications correctly.
d) Implementation involves carrying out the planned interventions, such as physically setting up the pill organizer or educating the patient on medication use.
Correct Answer is D
Explanation
A. Assessment involves gathering data about the patient’s condition, but in this case, the nurse and patient are making a decision about discharge criteria, which falls under planning.
B. Evaluation occurs after interventions have been implemented to determine whether goals have been met. Since the patient has not yet attempted self-care, this phase has not been reached.
C. Implementation refers to carrying out nursing interventions, such as administering medications or assisting with breathing exercises. The discussion about discharge criteria is a planning activity rather than an intervention.
D. Planning involves setting goals and determining the criteria for discharge, which is what the nurse and patient are doing by establishing that the patient may go home when self-care can be performed without dyspnea or hypoxia.
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