Objective:Ch01:TheNursingProcessandDrugTherapy
1.QuestionName:0001Type:MCObjective:Ch01:TheNursingProcessandDrugTherapyItemBank:Lilley
PharmacologyandtheNursingProcess7thEd
Thenurseiswritinganursingdiagnosisforaplanofcareforapatientwhohasbeennewly
diagnosedwithtype2diabetes.Whichstatementreflectsthecorrectformatforanursing
diagnosis?
A.Anxiety
B.Anxietyrelatedtonewdrugtherapy
C.Anxietyrelatedtoanxiousfeelingsaboutdrugtherapy,asevidencedbystatementssuchas
“I’mupsetabouthavingtotestmybloodsugars.”
*D.Anxietyrelatedtonewdrugtherapy,asevidencedbystatementssuchas“I’mupsetabout
havingtotestmybloodsugars.”
CorrectAnswer:D
Explanation/Rationale:
ANS:D
Formulationofnursingdiagnosesisusuallyathree-stepprocess.“Anxiety”ismissingthe
“relatedto”and“asevidencedby”portionsofdefiningcharacteristics.“Anxietyrelatedtonew
drugtherapy”ismissingthe“asevidencedby”portionofdefiningcharacteristics.Thestatement
beginning“Anxietyrelatedtoanxiousfeelings”isincorrectbecausethe“relatedto”sectionis
simplyarestatementoftheproblem“anxiety,”notaseparatefactorrelatedtotheresponse.
DIF:COGNITIVELEVEL:Understanding(Comprehension)REF:p.9
TOP:NURSINGPROCESS:NursingDiagnosis
MSC:NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
Reference/Notes:
Keywords:
Points: 1.00 Penalty: 0.00 ScoreMode:Active
DateCreated:01/31/1314:18:01DateModified:01/31/1314:18:01DateUsed:
Difficulty:Easy Discrimination:Low
ItemAnalysis:Last ItemAnalysis:Cumulative
No.ofStudentsResponded:0 No.ofStudentsResponded:0
CorrectResponses(%): CorrectResponses(%):
TotalGroup: 0.00 TotalGroup: 0.00
Upper27%ofGroup: 0.00 Upper27%ofGroup: 0.00
Lower27%ofGroup: 0.00 Lower27%ofGroup: 0.00
PointBiserial: 0.00 PointBiserial: 0.00
ResponseFrequencies(%) A B C D
Last: 0.000.000.000.00
Cumulative:0.000.000.000.00
2.QuestionName:0002Type:MCObjective:Ch01:TheNursingProcessandDrugTherapyItemBank:Lilley
PharmacologyandtheNursingProcess7thEd
Thepatientistoreceiveoralguaifenesin(Mucinex)twiceaday.Today,thenursewasbusyand
gavethemedication2hoursafterthescheduleddosewasdue.Whattypeofproblemdoesthis
represent?
*A.“Righttime”problem
B.“Rightdose”problem
C.“Rightroute”problem
D.“Rightmedication”problem
CorrectAnswer:A
Explanation/Rationale:
ANS:A
“Righttime”iscorrectbecausethemedicationwasgivenmorethan30minutesafterthe
scheduleddosewasdue.“Dose”isincorrectbecausethedoseisnotrelatedtothetimethe
medicationadministrationisscheduled.“Route”isincorrectbecausetherouteisnotaffected.
“Medication”isincorrectbecausethemedicationorderedwillnotchange.
DIF:COGNITIVELEVEL:Applying(Application)REF:p.13
TOP:NURSINGPROCESS:Implementation
MSC:NCLEX:SafeandEffectiveCareEnvironment:SafetyandInfectionControl
Reference/Notes:
Keywords:
Points: 1.00 Penalty: 0.00 ScoreMode:Active
DateCreated:01/31/1314:18:01DateModified:01/31/1314:18:01DateUsed:
Difficulty:Easy Discrimination:Low
ItemAnalysis:Last ItemAnalysis:Cumulative
No.ofStudentsResponded:0 No.ofStudentsResponded:0
CorrectResponses(%): CorrectResponses(%):
TotalGroup: 0.00 TotalGroup: 0.00
Upper27%ofGroup: 0.00 Upper27%ofGroup: 0.00
Lower27%ofGroup: 0.00 Lower27%ofGroup: 0.00
PointBiserial: 0.00 PointBiserial: 0.00
ResponseFrequencies(%)
A B C D
Last: 0.000.000.000.00
Cumulative:0.000.000.000.00 3.QuestionName:0003Type:MCObjective:Ch01:TheNursingProcessandDrugTherapyItemBank:Lilley
PharmacologyandtheNursingProcess7thEd
Thenursehasbeenmonitoringthepatient’sprogressonanewdrugregimensincethefirstdose
anddocumentingthepatient’stherapeuticresponsetothemedication.Whichphaseofthenursing
processdotheseactionsillustrate?
A.Nursingdiagnosis
B.Planning
C.Implementation
*D.Evaluation
CorrectAnswer:D
Explanation/Rationale:
ANS:D
Monitoringthepatient’sprogress,includingthepatient’sresponsetothemedication,ispartof
theevaluationphase.Planning,implementation,andnursingdiagnosisarenotillustratedbythis
example.
DIF:COGNITIVELEVEL:Understanding(Comprehension)REF:p.15
TOP:NURSINGPROCESS:Evaluation
MSC:NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
Reference/Notes:
Keywords:
Points: 1.00 Penalty: 0.00 ScoreMode:Active
DateCreated:01/31/1314:18:01DateModified:01/31/1314:18:01DateUsed:
Difficulty:Easy Discrimination:Low
ItemAnalysis:Last ItemAnalysis:Cumulative
No.ofStudentsResponded:0 No.ofStudentsResponded:0
CorrectResponses(%): CorrectResponses(%):
TotalGroup: 0.00 TotalGroup: 0.00
Upper27%ofGroup: 0.00 Upper27%ofGroup: 0.00
Lower27%ofGroup: 0.00 Lower27%ofGroup: 0.00
PointBiserial: 0.00 PointBiserial: 0.00
ResponseFrequencies(%)
A B C D
Last: 0.000.000.000.00
Cumulative:0.000.000.000.00
4.QuestionName:0004Type:MCObjective:Ch01:TheNursingProcessandDrugTherapyItemBank:Lilley PharmacologyandtheNursingProcess7thEd
Thenurseisassignedtoapatientwhoisnewlydiagnosedwithtype1diabetesmellitus.Which
statementbestillustratesanoutcomecriterionforthispatient?
A.Thepatientwillfollowinstructions.
B.Thepatientwillnotexperiencecomplications.
C.Thepatientwilladheretothenewinsulintreatmentregimen.
*D.Thepatientwilldemonstratecorrectbloodglucosetestingtechnique.
CorrectAnswer:D
Explanation/Rationale:
ANS:D
“Demonstratingcorrectbloodglucosetestingtechnique”isaspecificandmeasurableoutcome
criterion.“Followinginstructions”and“notexperiencingcomplications”arenotspecificcriteria.
“Adheringtonewregimen”wouldbedifficulttomeasure.
DIF:COGNITIVELEVEL:Applying(Application)REF:p.11
TOP:NURSINGPROCESS:Planning
MSC:NCLEX:SafeandEffectiveCareEnvironment:ManagementofCare
Reference/Notes:
Keywords:
Points: 1.00 Penalty: 0.00 ScoreMode:Active
DateCreated:01/31/1314:18:01DateModified:01/31/1314:18:01DateUsed:
Difficulty:Easy Discrimination:Low
ItemAnalysis:Last ItemAnalysis:Cumulative
No.ofStudentsResponded:0 No.ofStudentsResponded:0
CorrectResponses(%): CorrectResponses(%):
TotalGroup: 0.00 TotalGroup: 0.00
Upper27%ofGroup: 0.00 Upper27%ofGroup: 0.00
Lower27%ofGroup: 0.00 Lower27%ofGroup: 0.00
PointBiserial: 0.00 PointBiserial: 0.00
ResponseFrequencies(%)
A B C D
Last: 0.000.000.000.00
Cumulative:0.000.000.000.00
5.QuestionName:0005Type:MCObjective:Ch01:TheNursingProcessandDrugTherapyItemBank:Lilley
PharmacologyandtheNursingProcess7thEd
Whichactivitybestreflectstheimplementationphaseofthenursingprocessforthepatientwhois
newlydiagnosedwithhypertension?
*A.Providingeducationonkeepingajournalofbloodpressurereadings
B.Settinggoalsandoutcomecriteriawiththepatient’sinput