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dition Linda Lane Lilley, Shelly Rainforth Collins, Julie S. Snyder
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Chapter 01: The Nursing Process and Drug Therapy
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MULTIPLE CHOICE te
1. The nurse is writing a nursing diagnosis for a plan of care for a patient who h
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as been newlydiagnosed with type 2 diabetes. Which statement reflects the co
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rrect format for a nursing diagnosis?
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a. Anxiety
b. Anxiety related to new drug therapy te te te te te
c. Anxiety related to anxious feelings about drug therapy, as evidenced by
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statements
such as “I’m upset about having to test my blood sugars.”
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d. Anxiety related to new drug therapy, as evidenced by statements such as
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e “I’m
upset about having to test my blood sugars.”
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ANS: D te
Formulation of nursing diagnoses is usually a three-
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step process. “Anxiety” is missing the
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“related to” and “as evidenced by” portions of defining characteristics. “Anxiety r
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elated to new drug therapy” is missing the “as evidenced by” portion of defining c
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haracteristics. The statementbeginning “Anxiety related to anxious feelings” is inc
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orrect because the “related to” section is simply a restatement of the problem “anxi
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ety,” not a separate factor related to the response.
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DIF:
, COGNITIVE LEVEL: Understanding (Co te te te
mprehension)TOP: NURSING PROCESS: Nurs te t e te te
ing Diagnosis
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MSC: NCLEX: Safe and Effective Care Environment: Management of Care
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2. The patient is to receive oral guaifenesin (Mucinex) twice a day. Today, the nurse
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ewas busy andgave the medication 2 hours after the scheduled dose was due. Wha
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t type of problem does this represent?
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a. “Right time” te
b. “Right dose” te
c. “Right route” te
d. “Right medication te
”
ANS: A te
“Right time” is correct because the medication was given more than 30 minu
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tes after the scheduled dose was due. “Dose” is incorrect because the dose is
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not related to the time the
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medication administration is scheduled. “Route” is incorrect because the route i
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s not affected.“Medication” is incorrect because the medication ordered will not
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te change.
DIF:
COGNITIVE LEVEL: Applying (A te te te
pplication)TOP: NURSING PROCESS: I te t e te te
mplementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
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3. The nurse has been monitoring the patient’s progress on a new drug regimen sinc
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e the first doseand documenting the patient’s therapeutic response to the medicati
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, on. Which phase of the nursing process do these actions illustrate?
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a. Nursing diagnosi te
s
b. Planning
c. Implementatio
n
d. Evaluation
ANS: D te
Monitoring the patient’s progress, including the patient’s response to the medicati
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on, is part of the evaluation phase. Planning, implementation, and nursing diagnos
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is are not illustrated by thisexample.
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DIF:
COGNITIVE LEVEL: Understanding (Co te te te
mprehension)TOP: NURSING PROCESS: Eval te t e te te
uation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
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4. The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes m
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ellitus. Whichstatement best illustrates an outcome criterion for this patient?
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a. The patient will follow instructions.
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b. The patient will not experience complications.
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c. The patient will adhere to the new insulin treatment regimen
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.
d. The patient will demonstrate correct blood glucose testing te
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chnique.
ANS: D te
, “Demonstrating correct blood glucose testing technique” is a specific and measura
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ble outcome criterion. “Following instructions” and “not experiencing complicatio
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ns” are not specific criteria.“Adhering to new regimen” would be difficult to meas
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ure.