Chapter 01: The Nursing Process and Drug Therapy
1. The nurse is writing a nursing diagnosis for a plan of care for a patient who has been
... [Show More] newly
diagnosed with type 2 diabetes. Which statement reflects the correct format for a nursing
diagnosis?
a. Anxiety
b. Anxiety related to new drug therapy
c. Anxiety related to anxious feelings about drug therapy, as evidenced by statements
VXch aV ³I¶P XSVeW abRXW haYiQg WR WeVW P\ bORRd VXgaUV.´
d. AQ[ieW\ UeOaWed WR QeZ dUXg WheUaS\, aV eYideQced b\ VWaWePeQWV VXch aV ³I¶P
upset about having to test my blood VXgaUV.´
ANS: D
Formulation of nursing diagnoses is usually a three-VWeS SURceVV. ³AQ[ieW\´ iV PiVViQg Whe
³UeOaWed WR´ aQd ³aV eYideQced b\´ SRUWiRQV Rf defiQiQg chaUacWeUiVWicV. ³AQ[ieW\ UeOaWed WR QeZ
dUXg WheUaS\´ iV PiVViQg Whe ³aV eYideQced b\´ portion of defining characteristics. The statement
begiQQiQg ³AQ[ieW\ UeOaWed WR aQ[iRXV feeOiQgV´ iV iQcRUUecW becaXVe Whe ³UeOaWed WR´ VecWiRQ iV
ViPSO\ a UeVWaWePeQW Rf Whe SURbOeP ³aQ[ieW\,´ QRW a VeSaUaWe facWRU UeOaWed WR Whe UeVSRQVe.
DIF: COGNITIVE LEVEL: Understanding (Comprehension)
TOP: NURSING PROCESS: Nursing Diagnosis
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. The patient is to receive oral guaifenesin (Mucinex) twice a day. Today, the nurse was busy and
gave the medication 2 hours after the scheduled dose was due. What type of problem does this
represent?
a. ³RighW WiPe´
b. ³RighW dRVe´
c. ³RighW URXWe´
d. ³RighW PedicaWiRQ´
ANS: A
³RighW WiPe´ iV cRUUecW becaXVe Whe PedicaWiRQ ZaV giYeQ PRUe WhaQ 30 minutes after the
VchedXOed dRVe ZaV dXe. ³DRVe´ iV iQcRUUecW becaXVe Whe dRVe iV QRW UeOaWed WR Whe WiPe Whe
PedicaWiRQ adPiQiVWUaWiRQ iV VchedXOed. ³RRXWe´ iV iQcRUUecW becaXVe Whe URXWe iV QRW affecWed.
³MedicaWiRQ´ iV iQcRUUecW becaXVe Whe PedicaWiRQ Rrdered will not change.
DIF: COGNITIVE LEVEL: Applying (Application)
TOP: NURSING PROCESS: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
3. The QXUVe haV beeQ PRQiWRUiQg Whe SaWieQW¶V SURgUeVV RQ a QeZ drug regimen since the first dose
aQd dRcXPeQWiQg Whe SaWieQW¶V WheUaSeXWic UeVSRQVe WR Whe PedicaWiRQ. Which ShaVe Rf Whe
nursing process do these actions illustrate?
a. Nursing diagnosis
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Chapter 01: The Nursing Process and Drug Therapy 5
b. Planning
c. Implementation
d. Evaluation
ANS: D
Monitoring Whe SaWieQW¶V SURgUeVV, iQcOXdiQg Whe SaWieQW¶V UeVSRQVe WR Whe PedicaWiRQ, iV SaUW Rf
the evaluation phase. Planning, implementation, and nursing diagnosis are not illustrated by this
example.
DIF: COGNITIVE LEVEL: Understanding (Comprehension)
TOP: NURSING PROCESS: Evaluation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
4. The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes mellitus. Which
statement best illustrates an outcome criterion for this patient?
a. The patient will follow instructions.
b. The patient will not experience complications.
c. The patient will adhere to the new insulin treatment regimen.
d. The patient will demonstrate correct blood glucose testing technique.
ANS: D
³DePRQVWUaWiQg cRUUecW bORRd gOXcRVe WeVWiQg WechQiTXe´ iV a VSecific aQd PeaVXUabOe RXWcRPe
cUiWeUiRQ. ³FROORZiQg iQVWUXcWiRQV´ aQd ³QRW e[SeUieQciQg cRPSOicaWiRQV´ aUe QRW VSecific cUiWeUia.
³AdheUiQg WR QeZ UegiPeQ´ ZRXOd be difficXOW WR PeaVXUe.
DIF: COGNITIVE LEVEL: Applying (Application)
TOP: NURSING PROCESS: Planning
MSC: NCLEX: Safe and Effective Care Environment: Management of Care [Show Less]