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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 c/t c/t c/t c/t c/t c/t c/t c/t
MULTIPLE CHOICE c/t
1. Allofthefollowing wouldbeconsidered subjective data, EXCEPT:
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a. Patient-reportedhealthhistory c/t c/t
b. Patient-reportedsignsandsymptoms oftheirillness c/t c/t c/t c/t c/t c/t
c. Financialbarriersreportedbythepatient’s caregiver c/t c/t c/t c/t c/t c/t
d. Vitalsignsobtainedfromthemedical record c/t c/t c/t c/t c/t c/t
ANS: D c / t
Subjectivedataisbased onwhatpatientsorfamilymemberscommunicate tothenurse.Patient- reported c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t
health history, 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) c/t c /t c/t TOP: NursingProcess:Planning c /t c/t c/t
MSC: NCLEX: Management of Client Care
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2. Thenurseisusingdatacollected to defineasetof interventions toachievethemostdesirable
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c/t outcomes. Which of the following steps is the nurse applying? c/t c/t c/ t c/t c/ t c /t c /t c/t c /t
a. Recognizingcues(assessment) c/t c/t
b. Analyzecues&prioritizehypothesis(analysis) c/t c/t c/t c/t c/t
c. Generatesolutions(planning) c/t c/t
d. Takeaction(nursinginterventions) c/t c/t c/t
ANS: C c / t
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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Prioritizinghypothesisisusedtoorganizeandrankthepatientproblem(s) identified. Finally, taking
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actioninvolves implementation of nursing interventions to accomplish the expected outcomes.
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DIF: Cognitive Level: Understanding (Comprehension) c/t c/t c/t
TOP: Nursing Process: Nursing Intervention
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MSC: NCLEX:ManagementofClientCare c / t c/t c/t c/t c/t
3. A5-year-old child with type1diabetes mellitus hashadrepeatedhospitalizations forepisodesof
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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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carefortheirchild.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 arecompleted in which step of the
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nursing process?
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a. Recognizingcues(assessment) c/t c/t
b. Analyzecues&prioritizehypothesis(analysis) c/t c/t c/t c/t c/t
, c. Generatesolutions(planning) c/t c/t
d. Takeaction(nursinginterventions) c/t c/t c/t
ANS: D c / t
Takingactionthroughnursinginterventionsiswherethenurseprovidespatienthealthteaching, 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) c/t c/t c/t
TOP: Nursing Process: Nursing Intervention
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MSC: NCLEX:ManagementofClientCare c / t c/t c/t c/t c/t
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) c/t c/t
b. Analyzecues&prioritizehypothesis(analysis) c/t c/t c/t c/t c/t
c. Takeaction(nursinginterventions) c/t c/t c/t
d. Generatesolutions(planning) c/t c/t
ANS: A c / t
Recognizingcues(assessment)involvesgatheringsubjectiveandobjectiveinformationaboutthe c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t
patient and the medication. Laboratory values from the patient’s chart would be considered
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collection of objective data.
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DIF: Cognitive Level: Understanding(Comprehension) c /t c /t c/t
TOP: NursingProcess: Assessment cMSC: NCLEX:ManagementofClientCare
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5. Whichofthe followingwouldbecorrectlycategorized as objective data?
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a. Alist ofherbalsupplements regularlyused provided bythe patient.
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b. Labvalues associated with thedrugs thepatient istaking. c/t c/t c/t c/t c/t c/t c/t c/t c/t
c. Theagesand relationship ofallhousehold members tothepatient. c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t
d. Usualdietarypatternsandfoodintake. c/t c/t c/t c/t c/t
ANS: B c / t
Objectivedataaremeasuredanddetectedbyanotherpersonandwould includelabvalues.The other c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t
examples are subjective data.
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DIF: Cognitive Level: Understanding(Comprehension) c /t c /t c/t
TOP: NursingProcess: Assessment cMSC: 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
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not have an established routine. The patient will be sent home with three new medications tobetaken
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atdifferent times oftheday. Thenursedevelops adailymedicationchart and enlists a family member
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to put the patient’s pills in a pill organizer. This is an example of which element of the nursing
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process?
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a. Recognizingcues(assessment) c/t c/t
b. Analyzecues&prioritizehypothesis(analysis) c/t c/t c/t c/t c/t
c. Takeaction(nursinginterventions) c/t c/t c/t
, d. Generatesolutions(planning) c/t c/t
ANS: C c / t
Takingaction(nursinginterventions)involveseducationandpatient carein ordertoassistthe patient to
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accomplish the goals of treatment.
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DIF: Cognitive Level: Applying(Application) c/t c/t c/t
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 thepatient discuss thepatient’s situationanddecidethatthepatient maygo home when
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able to perform self-carewithout dyspnea and hypoxia. This is an exampleof which phase of the
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nursing process?
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a. Recognizingcues(assessment) c/t c/t
b. Analyzecues&prioritizehypothesis(analysis) c/t c/t c/t c/t c/t
c. Takeaction(nursinginterventions) c/t c/t c/t
d. Generatesolutions(planning) c/t c/t
ANS: D c / t
Generating solutions (planning) involves defining a set of interventions to achieve the most c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t
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 besenthomewithametered-doseinhaler,and thenurseisprovidingteaching. Which
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c/t is a correctly written expected outcome for this process?
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a. Thenursewilldemonstrate thecorrect useof ametered-doseinhaler to thepatient. c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t
b. Thenursewillteachthepatienthowtoadministermedicationwithametered-dose c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t
inhaler.
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c. Thepatientwillknowhowtoself-administerthemedicationusingthemetered- dose c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t c/t
inhaler.
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d. Thepatientwillindependentlyadministerthemedicationusingthemetered-dose c/t c/t c/t c/t c/t c/t c/t c/t c/t
inhaler at the end of the session.
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ANS: D c / t
Expected outcomes must be patient-centered and clearly state the outcome with a reasonable c/t c/t c/t ct/ c/t c/t c/t c/t c/t c/t c/t c/t
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 hasbeenadmittedforincreasedoxygenneeds aboveabaselineof2 L/min. Thenurse
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generates an expected outcomes stating, “Thepatient will haveoxygen saturations of
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>95%on roomair at the time ofdischarge from thehospital.”What is wrongwith this goal?
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a. Itcannotbeevaluated. c/t c/t c/t