Author Question: A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900 . The ... (Read 87 times)

urbanoutfitters · **on:** Jul 22, 2018

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900 . The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830 .

The nursing assistant states she was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process? a. Assessment
b. Diagnosis
c. Planning
d. Evaluation

Question 2

The patient has been diagnosed with diabetes for the past 12 years. When admitted, the patient is unkempt and is in need of a bath and foot care.

When questioned about his hygiene habits, the patient tells the nurse that baths are taken once a week where he comes from, although he takes a sponge bath every other day. To provide ultimate care for this patient, the nurse understands that a. Personal preferences determine hygiene practices and are unchangeable.
b. Patients who appear unkempt place little importance on hygiene practices.
c. The patient's illness may require teaching of new hygiene practices.
d. All cultures value cleanliness with the same degree of importance.

coyin · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

A
The diagnostic process should flow from the assessment. Without a thorough assessment, the nurse is more apt to misdiagnose a patient's responses, and the wrong interventions may be implemented. In this case, the nurse should have assessed the patient's blood pressure before giving the medication. The nurse could have prevented the patient's untoward reaction if the low blood pressure was assessed first. The nurse could have notified the physician, held the medication, or taken other steps to prevent an adverse reaction.

Answer to Question 2

C
Each patient has individual desires and preferences about when to bathe, shave, and perform hair care. However, they are not unchangeable. In addition, the nurse must assist the patient in developing new hygiene practices when indicated by an illness or condition. For example, the nurse will need to teach a patient with diabetes proper foot hygiene. Patients who appear unkempt often need further assessment regarding their ability to participate in daily hygiene. Patients with certain types of physical limitations or disabilities often lack the physical energy and dexterity to perform hygienic care. Culturally, maintaining cleanliness does not hold the same importance for some ethnic groups as it does for others.