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Nursing Process Approach, 11th Edition by
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Linda E. McCuistion Chapter 1-58
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,Chapter01:TheNursingProcessandPatient-CenteredCare
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McCuistion:Pharmacology:APatient-CenteredNursingProcessApproach,11thEdition j
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MULTIPLE CHOICE nj
1. Allofthefollowing wouldbeconsidered subjective data, EXCEPT:
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a. Patient-reportedhealthhistory nj nj
b. Patient-reportedsigns andsymptoms oftheirillness nj nj nj nj nj nj
c. Financialbarriersreportedbythepatient’s caregiver nj nj nj nj nj nj
d. Vitalsignsobtainedfromthemedical record nj nj nj nj nj nj
ANS: D n j
Subjective dataisbased onwhat patients orfamilymemberscommunicate tothenurse.Patient- reported nj nj nj nj nj nj nj nj nj nj nj nj nj nj nj
healthhistory, signs and symptoms, and caregiver reported financialbarriers would be considered
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subjective data. Vital signs obtained from the medical record would be considered objective data.
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DIF: Cognitive Level: Understanding (Comprehension) nj nj nj TOP: NursingProcess:Planning n j nj nj
MSC: NCLEX: Management of Client Care
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2. Thenurseisusingdatacollectedto define asetof interventions to achievethemostdesirable
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nj outcomes. Which of the following steps is the nurse applying? nj nj nj nj nj nj nj nj nj
a. Recognizingcues(assessment) nj nj
b. Analyzecues&prioritizehypothesis(analysis) nj nj nj nj nj
c. Generatesolutions(planning) nj nj
d. Takeaction(nursinginterventions) nj nj nj
ANS: C n j
When generating solutions (planning), the nurse identifies expected outcomes and uses the patient’s
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problem(s) to define a set of interventions to achieve the most desirable outcomes. Recognizing cues
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(assessment) involves the gathering of cues (information) from the patient about their health and
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lifestyle practices, which are important facts that aid the nurse in making clinicalcaredecisions.
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Prioritizinghypothesis isusedtoorganizeandrankthepatientproblem(s) identified.Finally, taking
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actioninvolves implementationof nursing interventions to accomplish the expected outcomes.
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DIF: Cognitive Level: Understanding (Comprehension) nj nj nj
TOP: Nursing Process: Nursing Intervention
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MSC: NCLEX:ManagementofClientCare n j nj nj nj nj
3. A5-year-oldchild with type1diabetes mellitus hashadrepeated hospitalizations forepisodes of
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hyperglycemia. The parents tell the nurse that they can’t keep track of everything that has to be doneto
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carefor theirchild.Thenursereviews medications, diet,andsymptom management with the parents
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and draws up a daily checklist for the family to use. These activities are completed in which step of the
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nursing process?
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a. Recognizingcues(assessment) nj nj
b. Analyzecues&prioritizehypothesis(analysis) nj nj nj nj nj
, c. Generatesolutions(planning) nj nj
d. Takeaction(nursinginterventions) nj nj nj
ANS: D n j
Takingactionthroughnursinginterventionsiswherethenurseprovidespatient healthteaching, drug
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administration, patient care, and other interventions necessary to assist the patient in accomplishing
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expected outcomes.
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DIF: Cognitive Level: Understanding (Comprehension) nj nj nj
TOP: Nursing Process: Nursing Intervention
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MSC: NCLEX:ManagementofClientCare n j nj nj nj nj
4. The nurse is preparing to administer a medication and reviews the patient’s chart for drug
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allergies, serum creatinine, and blood urea nitrogen (BUN) levels. The nurse’s actions are
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reflective of which of the following?
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a. Recognizingcues(assessment) nj nj
b. Analyzecues&prioritizehypothesis(analysis) nj nj nj nj nj
c. Takeaction(nursinginterventions) nj nj nj
d. Generatesolutions(planning) nj nj
ANS: A n j
Recognizingcues(assessment)involvesgatheringsubjectiveandobjectiveinformationaboutthe nj nj nj nj nj nj nj nj nj nj
patient and the medication. Laboratory values from the patient’s chart would be considered collection
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of objective data.
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DIF: Cognitive Level: Understanding(Comprehension) nj nj nj
TOP: NursingProcess: Assessment n MSC: NCLEX:ManagementofClientCare
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5. Whichofthe followingwouldbecorrectlycategorized asobjective data?
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a. Alist ofherbalsupplements regularlyused provided bythe patient.
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b. Labvalues associated with thedrugs thepatient is taking. nj nj nj nj nj nj nj nj nj
c. Theagesand relationship ofallhousehold members to thepatient. nj nj nj nj nj nj nj nj nj nj
d. Usualdietarypatterns andfoodintake. nj nj nj nj nj
ANS: B n j
Objective dataaremeasuredanddetectedbyanotherpersonandwould includelabvalues.The other nj nj nj nj nj nj nj nj nj nj nj nj nj nj nj
examples are subjective data.
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DIF: Cognitive Level: Understanding(Comprehension) nj nj nj
TOP: NursingProcess: Assessment n MSC: NCLEX:ManagementofClientCare
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6. The nurse reviews a patient’s database and learns that the patient lives alone, is forgetful, and does not
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have an established routine. The patient will be sent home with three new medications tobetakenat
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differenttimes oftheday. Thenursedevelops adailymedicationchart and enlists a family member to
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put the patient’s pills in a pill organizer. This is an example of which element of the nursing process?
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a. Recognizingcues(assessment) nj nj
b. Analyzecues&prioritizehypothesis(analysis) nj nj nj nj nj
c. Takeaction(nursinginterventions) nj nj nj
, d. Generatesolutions(planning) nj nj
ANS: C n j
Takingaction(nursinginterventions)involveseducationandpatient carein ordertoassistthe patient to
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accomplish the goals of treatment.
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DIF: CognitiveLevel: Applying(Application) nj nj nj
TOP: Nursing Process: Nursing Intervention
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MSC: NCLEX: Management of Client Care
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7. A patient who is hospitalized for chronic obstructive pulmonary disease (COPD) wants to go home.
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Thenurseand thepatientdiscuss the patient’s situationanddecidethatthepatient maygo home when
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able to perform self-carewithout dyspnea and hypoxia. This is an example of which phase of the
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nursing process?
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a. Recognizingcues(assessment) nj nj
b. Analyzecues&prioritizehypothesis(analysis) nj nj nj nj nj
c. Takeaction(nursinginterventions) nj nj nj
d. Generatesolutions(planning) nj nj
ANS: D n j
Generating solutions (planning) involves defining a set of interventions to achieve the most nj nj nj nj nj nj nj nj nj nj nj nj
desirable outcomes, which, for this patient, means being able to perform self-care activities
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without dyspnea and hypoxia.
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DIF: Cognitive Level: Understanding (Comprehension)
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MSC: NCLEX: Management of Client Care
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8. Apatientwill besent homewith ametered-doseinhaler,and thenurseisprovidingteaching. Which
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nj is a correctly written expected outcome for this process?
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a. Thenursewilldemonstrate thecorrect useof a metered-doseinhaler to thepatient.
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b. Thenursewillteach thepatienthowtoadministermedicationwithametered-dose nj nj nj nj nj nj nj nj nj nj nj nj
inhaler.
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c. Thepatientwillknowhowtoself-administerthemedicationusingthemetered- dose nj nj nj nj nj nj nj nj nj nj nj nj
inhaler.
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d. Thepatientwillindependentlyadministerthemedicationusingthemetered-dose nj nj nj nj nj nj nj nj nj
inhaler at the end of the session.
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ANS: D n j
Expected outcomes must be patient-centered and clearly state the outcome with a reasonable nj nj nj nj nj nj nj nj nj nj nj nj
deadline and should identify components for evaluation.
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DIF: Cognitive Level: Applying (Application)
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MSC: NCLEX: Management of Client Care
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9. The nurse is generating solutions (planning) for a patient who has chronic lung disease and hypoxia.
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Thepatient hasbeen admittedforincreasedoxygenneeds aboveabaselineof2 L/min. Thenurse
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generates an expected outcomes stating, “The patient will have oxygen saturations of
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>95%on roomair at the time ofdischarge from the hospital.”What iswrongwith this goal?
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a. Itcannotbeevaluated. nj nj nj