Lilley: Pharmacology and the Nursing Process, 9th Edition
MULTIPLE CHOICE
The nurse is writing a nursing diagnosis for a plan of care for a patient who has
been 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
Anxiety related to anxious feelings about drug therapy, as evidenced by
c.
statements such as “I’m upset about having to test my blood sugars.”
Anxiety related to new drug therapy, as evidenced by statements such as “I’m
d.
upset about having to test my blood sugars.”
ANS: D
Formulation of nursing diagnoses is usually a three-step process. “Anxiety” is
missing the “related to” and “as evidenced by” portions of defining
characteristics. “Anxiety related to new drug therapy” is missing the “as
evidenced by” portion of defining characteristics. The statement beginning
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, “Anxiety related to anxious feelings” is incorrect because the “related to” section
is simply a restatement of the problem “anxiety,” not a separate factor related to
the response.
DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: p. 7
TOP: NURSING PROCESS: Nursing Diagnosis
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
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. “Right time”
b. “Right dose”
c. “Right route”
d. “Right medication”
ANS: A
“Right time” is correct because the medication was given more than 30 minutes
after the scheduled dose was due. “Dose” is incorrect because the dose is not
related to the time the medication administration is scheduled. “Route” is
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, incorrect because the route is not affected. “Medication” is incorrect because the
medication ordered will not change.
DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 11
TOP: NURSING PROCESS: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection
Control
The nurse has been monitoring the patient’s progress on a new drug regimen since
the first dose and documenting the patient’s therapeutic response to the
medication. Which phase of the nursing process do these actions illustrate?
a. Nursing diagnosis
b. Planning
c. Implementation
d. Evaluation
ANS: D
Monitoring the patient’s progress, including the patient’s response to the
medication, is part of the evaluation phase. Planning, implementation, and
nursing diagnosis are not illustrated by this example.
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, DIF: COGNITIVE LEVEL: Understanding (Comprehension) REF: pp. 13-14
TOP: NURSING PROCESS: Evaluation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
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
“Demonstrating correct blood glucose testing technique” is a specific and
measurable outcome criterion. “Following instructions” and “not experiencing
complications” are not specific criteria. “Adhering to new regimen” would be
difficult to measure.
DIF: COGNITIVE LEVEL: Applying (Application) REF: p. 8
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