Answer to Question 1
B
Evaluation is the final step of the nursing process. It is a planned, ongoing, systematic activity in which a nurse will make judgments about patient progress toward desired health outcomes, effectiveness of the nursing care plan, and the quality of nursing care in the healthcare setting. Evaluation data are collected after interventions are performed to determine whether patient goals were achieved. In this item, obtaining a patient's blood pressure after administering blood pressure medications evaluates the patient's response to the medication. Administering pain medication prior to performing a dressing change is an intervention, as is teaching a patient to perform an Accu-Chek. Reporting patient falls is part of the assessment process.
Answer to Question 2
A
Lazy implies criticism of the client and therefore is judgmental. There need to be several (certainly more than two) etiological factors for the statement to be complex. There is no blame implied or harm resulting, so the statement is not legally questionable. There is no minimum amount of supportive data for a diagnosis and the stated etiology related to the nursing diagnosis. No supportive data are given in the stem of the question, so you could not choose lack of data as the best answer because all the options lack data as far as you can tell from the information given in the question. In addition, it is not necessary to include supportive data in the diagnostic statement (although some do prefer to use AMB and include defining characteristics).
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