,Chapter 01: The Nursing Process and Patient-Centered Care
b b b b b b b
McCuistion: Pharmacology: A Patient-Centered Nursing Process Approach, 11th Edition
b b b b b b b b
MULTIPLE CHOICE b
1. All of the following would be considered subjective data,
b b b b b b b b b EXCEPT:
a. Patient-reported health history b b
b. Patient-reported signs and symptoms of their illness b b b b b b
c. Financial barriers reported by the patient’s caregiver b b b b b b
d. Vital signs obtained from the medical record b b b b b b
ANS: D
Subjective data is based on what patients or family members communicate to
b b b b b b b b b b b
thenurse. Patient- reported health history, signs and symptoms, and caregiver reported
b b b b b b b b b b b b
financial barriers would be considered subjective data. Vital signs obtained from the
b b b b b b b b b b b b
medical record would be considered objective data.
b b b b b b b
DIF: Cognitive Level: Understanding (Comprehension) b b b TOP: Nursing bb b
Process: Planning MSC:
b b b NCLEX: Management b
of Client Care
b b b
2. The nurse is using data collected to define a set of interventions to achieve
b b b b b b b b b b b b b
the most desirable outcomes.
b b Which of the b b b following steps is the b b
nurse applying?
b b
a. Recognizing cues (assessment) b b
b. Analyze cues & prioritize hypothesis (analysis) b b b b b
c. Generate solutions (planning) b b
d. Take action (nursing interventions) b b b
ANS: C
When generating solutions (planning), the nurse identifies expected outcomes
and uses the patient’s problem(s) to define a set of interventions to achieve the
b b b b b b b b b b b b b
most desirable outcomes. Recognizing cues (assessment) involves the gathering of
b b b b b b b b b b
cues (information) from the patient about their health and lifestyle practices,
b b b b b b b b b
whichare important facts that aid
b bthe nurse in makingclinical care
b b b b b
decisions.
b
Prioritizing hypothesis is used to organize and rank the patient problem(s) identified.
b b b b b b b b b b b
Finally, taking action involves implementation of nursing interventions to
b b b b b b b b bbb
accomplishthe expected outcomes.
b b b b
DIF: Cognitive Level: Understanding b b
(Comprehension) TOP: Nursing Process:
b b b
Nursing Intervention b
MSC: NCLEX: Management of Client b b b b Care
3. A 5-year-old child with type 1 diabetes mellitus has had repeated hospitalizations for
b b b b b b b b b b b b
episodes of hyperglycemia. The parents tell the nurse that they can’t keep track of
b b b b b b b b b b b b b b
beverything that has to be done to care for their child. The nurse reviews b b b b b b b b b b bbb bbb bbb
bmedications, diet, and symptom management with the parents and draws up a daily b b b b b b b b b b b b
bchecklist for the family to use. These activities are completed inwhich step of
b b b bb b b bb b b bb b b bb b b
bthe nursing process?
a. Recognizing cues (assessment) b b
b. Analyze cues & prioritize hypothesis (analysis) b b b b b
, c. Generate solutions (planning) b b
d. Take action (nursing interventions) b b b
ANS: D
Taking action through nursing interventions is where the nurse provides patient health teaching,
b b b b b b b b b b b b
bdrug administration, patient care, and other interventions necessary to assist the
b b b b b b b b b b
patient in accomplishing expected outcomes.
b b b b b
DIF: Cognitive Level: Understanding b b
(Comprehension) TOP: Nursing Process:
b b b
Nursing Intervention b
MSC: NCLEX: Management of Client b b b b Care
4. The nurse is preparing to administer a medication and reviews the patient’s
b b b b b b b b b b b b b b b b b b b b b b b
chart for drug allergies, serum creatinine, and blood urea nitrogen (BUN)
b b b b b b b b b b b b b b b b b b b b b
levels. The nurse’s actions are reflective of which of the following?
b b b b b b b b b b b
a. Recognizing cues (assessment) b b
b. Analyze cues & prioritize hypothesis (analysis) b b b b b
c. Take action (nursing interventions) b b b
d. Generate solutions (planning) b b
ANS: A
Recognizing cues (assessment) involves gathering subjective and objective information
b b b b b b b b
about the patient and the medication. Laboratory values from the patient’s
b b b b b b b b b b b bb
chart would be considered collection of objective data.
b b b b b b b b
DIF: Cognitive Level: Understanding (Comprehension) b b b
TOP: Nursing Process: Assessment MSC: NCLEX: Management b b b b of Client b b Care
5. Which of the following would be correctly categorized as objective data?
b b b b b b b b b b
a. A list of herbal supplements regularly used provided by the patient.
b b b b b b b b b b
b. Lab values associated with the drugs the patient is taking.
b b b b b b b b b
c. The ages and relationship of all household members to the patient.
b b b b b b b b b b
d. Usual dietary patterns and food intake. b b b b b
ANS: B
Objective data are measured and detected by another person and would include lab
b b b b b b b b b b b b
values. The other examples are subjective data.
b b b b b b b
DIF: Cognitive Level: Understanding (Comprehension) b b b
TOP: Nursing Process: Assessment MSC: NCLEX: Management b b b b of b Client b Care
6. The nurse reviews a patient’s database and learns that the patient lives alone,
bb b bb b bb b
is forgetful, and does not have an established routine. The patient will be sent
b b b b b b b b bbb bbb bbb b bbb bbb
home with three new medications to be taken at different times of the day.
b b b b b b b b b b b b b b
The nurse develops a daily medication chart and enlists a family member to put the
b b b b b b b b b b b b b b b
patient’s pills in a pill organizer. This is b an example of b b b b
which element of thenursing process? b b
a. Recognizing cues (assessment) b b
b. Analyze cues & prioritize hypothesis (analysis) b b b b b
c. Take action (nursing interventions) b b b
, d. Generate solutions (planning) b b
ANS: C
Taking action (nursing interventions) involves education and patient care in order to
b b b b b b b b b b b
assist the patient to accomplish the goals of treatment.
b b b b b b b b b
DIF: Cognitive Level: Applying b b
(Application) TOP: Nursing
b b b
Process:
b
Nursing Intervention MSC: NCLEX: b b b
Management of Client Care b bb b bb b
7. A patient who is hospitalized for chronic obstructive pulmonary disease (COPD)
wants to go home. The nurse and the patient discuss the patient’s situation and
b b b b b b b b b b bbb bbb bbb bbb
decide that the patient may go home when able to perform self-care without
b b b b b b b b b b b b b
dyspneaand hypoxia. This is an example of which phase of the nursing process?
b b b b b b b b b b b b b b
a. Recognizing cues (assessment) b b
b. Analyze cues & prioritize hypothesis (analysis) b b b b b
c. Take action (nursing interventions) b b b
d. Generate solutions (planning) b b
ANS: D
Generating solutions (planning) involves defining a set of interventions to achieve
b b b b b b b b b b b b b b b b b b b bb b b b b b
the most desirable outcomes, which, for this patient, means being able
b b b b b b b b b b b
to perform self-care activities without dyspnea and hypoxia.
b b b b b b b b
DIF: Cognitive Level: Understanding (Comprehension)
bbbb b b b bbbbbb TOP: bbbbbb Nursing bbbbbb Process: Planning b
MSC: NCLEX: Management of Client Care
b b b b b b
8. A patient will be sent home with a metered-dose inhaler, and the nurse is
b b b b b b b b b b b b b
providing teaching. Which is a correctly written expected outcome for
b b b b b b b b
thisprocess?
b b
a. The nurse will demonstrate the correct use of a metered-dose inhaler
b b b b b b b b b b b to b the
patient.b
b. The nurse will teach the patient how to administer medication
b b b b b b b b b
with a metered-dose inhaler.
b b b b
c. The patient will know how to self-administer the medication
b b b b b b b b
usingthe metered- dose inhaler.
b b b b b
d. The patient will independently administer the medication using the
b b b b b b b b
metered- dose inhaler at the end of the session.
b b b b b b b b b
ANS: D
Expected outcomes must be patient-centered and clearly state the outcome
b b b b b b b b b b with b a
reasonable deadline and should identify components for evaluation.
b b b b b b b b
DIF: Cognitive Level: Applying (Application)
bb b b b b TOP: Nursing Process:Planning b b b bb b b
MSC: NCLEX: Management of Client Care
b b b b b b
9. The nurse is generating solutions (planning) for a patient who has chronic lung
b b b b b b b b b b b b
disease and hypoxia. The patient has been admitted for increased oxygen needs
b b b b b b b b b b
above a baseline of 2 L/min.
b The nurse generates an
b b expected b b b b b
outcomes stating,“The patient will have oxygen saturations of b b b b b b b b
>95% on room air at the time of discharge from the hospital.” What is wrong with
b b b b b b b b b b b b b b b
b thisgoal? b
a. It cannot be evaluated. b b b
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