Chapter 4 The Nursing Process and Pharmacology

23. Rank the patient needs according to Maslows hierarchy, beginning with the lowest level need to the highest level need. (Enter your answer with a comma and space between each lettered option as follows: A, B, C, D, E.) A. A patient would like to write a book. B. A patient becomes frightened when no one answers the call light during the night. C. A pediatric patient is worrying that school friends will forget him. D. A patient needs to be repositioned in bed. E. A chronically ill patient states that he feels worthless because he is unable to support his family.

ANS: D, B, C, E, A The needs should be addressed in the following order: The patients need for repositioning represents a basic need for comfort the patients alarm when the call light is not answered represents fear for safety the patients worry about his school friends forgetting him represents a threat to sense of love and belonging the patients feeling of worthlessness represents threatened self esteem and the patients desire to write a book is related to self actualization.

15. The nurse has determined that the pain medication given to a patient an hour ago has been effective. The nurse is using which step of the nursing process? a. Evaluation b. Intervention c. Nursing diagnosis d. Planning

ANS: A The nurse has used evaluation to assess the response to the administered medication. Intervention is the administration of the medication or teaching about the medication in this situation. This situation is not an example of making a nursing diagnosis. Planning is developing goal statements and prioritizing patient problems.

16. Prior to the administration of a nephrotoxic drug, the nurse determines that the kidney lab data are within normal range. Which step of the nursing process is being used? a. Assessment b. Nursing diagnosis c. Planning d. Evaluation

ANS: A The nurse is collecting information about renal function through lab data this is baseline assessment data. This action is not an example of the development of a nursing diagnosis. Planning is developing goal statements and prioritizing patient problems. Evaluation determines if goals have been met.

22. The nurse is preparing a patients prescribed medications. In order to ensure patient safety, the nurse will perform which intervention(s)? (Select all that apply.) a. Select the correct supplies. b. Administer the medication by the correct route. c. Use room number to identify correct patient. d. Educate patient regarding medications prescribed. e. Document in chart all aspects of medication administration.

ANS: A, B, D, E The nurse prepares prescribed medications using procedures to ensure patient safety, including selecting correct supplies, administering medication by the correct route, educating patients regarding medications prescribed, and documenting in chart all aspects of medication administration. To improve the accuracy of patient identification, it is now recommended that two patient identifiers, neither of which is the room number, be used when administering medications. Best practice would be to look at the patients name band for identity and to request that the patient state his or her name and birth date.

19. Which statement(s) regarding critical pathways is/are true? (Select all that apply.) a. Efficient for specific diseases or case types b. The same as medical plans c. Standardized and enhanced quality care d. Evaluated less frequently than care plans e. Enhanced communication for a variety of health care providers

ANS: A, C, E Critical pathways are standardized care plans that detail clinical interventions to be performed over a projected time frame for a specific disease or case type. Physician interventions are included in the pathways. Critical pathways enhance the quality of care and require evaluation and modification on an ongoing basis. Critical pathways assist as a communication system for all health care providers. Medical plans are distinct to physicians. Critical pathways should be evaluated as needed to achieve desired outcomes.

21. The nurse is participating in the planning phase of the nursing process for a new admission to a long term care facility. When formulating a plan to meet the patients needs, the nurse will take which action(s)? (Select all that apply.) a. Formulate nursing interventions. b. Collect data. c. Make a clinical judgment about the patient. d. Set priorities. e. Develop measurable goals.

ANS: A, D, E Planning is the third phase of the five step nursing process. Once the patient has been assessed and problems have been diagnosed, plans should be formulated to meet the patients needs. Planning usually encompasses four phases: (1) priority setting, (2) development of measurable goal and outcome statements, (3) formulation of nursing interventions, and (4) formulation of anticipated therapeutic outcomes that can be used to evaluate the patients status. Collecting data is part of the assessment phase of the nursing process. Making a clinical judgment about the patient takes place during the diagnosis phase.

12. What is a critical care pathway? a. A nursing care plan for a patient in a critical care unit b. A standardized care plan derived from best practice patterns c. A care plan that has been critiqued by a quality improvement officer d. A care plan based on measurable goals and outcomes

ANS: B A critical care pathway is a standardized care plan derived from best practice patterns, enabling the nurse to develop a treatment plan that sequences detailed clinical interventions to be performed over a projected amount of time for a specific case type of disease process. A nursing care plan for a patient in a critical care unit is not a critical care pathway. A care plan that has been critiqued by a quality improvement officer is not a critical care pathway. All good care plans are based on measurable goals and outcomes.

18. The nurse is prioritizing care of a pediatric patient diagnosed with cystic fibrosis. Which nursing diagnosis would the nurse consider the highest priority? a. Risk for altered nutrition: less than body related to decreased appetite b. Altered breathing pattern related to thickened mucus secretions c. Knowledge deficit related to disease process d. Impaired skin integrity related to decreased mobility

ANS: B Altered breathing pattern would be the highest priority because the physiologic need of oxygenation is required for total body function. Risk for altered nutrition, knowledge deficit, and impaired skin integrity would not be of higher priority than oxygenation.

5. What do the classification systems NIC and NOC provide? a. Individualized data banks of treatments related to disease processes b. Standardized language for reporting and analyzing nursing care delivery c. A measure for cost containment within medical institutions d. Specialized interventions for rare diseases

ANS: B Nursing classification systems such as NIC and NOC are designed to provide a standardized language for reporting and analyzing nursing care delivery that is individualized for each patient. Standardized terminology assists practitioners in the implementation of the five phases of the nursing process. Classification systems are not related to disease process and are not used for financial purposes. Classification systems include interventions for all health conditions.

10. An obese patient did not meet the goal of by the end of the second week, is able to follow a 1500 calorie diet. What will the nurse and the patient reassess? a. Patients weight b. Patients understanding of the 1500 calorie diet c. Nurses feelings about obese patients d. Health care agencys ability to provide the prescribed diet

ANS: B When goals are not met, the nurse must reassess the patients understanding of the interventions and commitment to reaching the identified goal. All phases of the nursing process are ongoing as the nurse continues to evaluate, assess, and readjust interventions as indicated to facilitate patient achievement of outcomes. The patient may have followed the diet but not lost any weight. The nurses feelings should not be a factor in the assessment. The agencys ability to provide the prescribed diet should have been determined before implementation of the plan.

6. Which type of nursing diagnosis will be written when the patient exhibits factors that makes him or her susceptible to the development of a problem? a. Actual diagnosis b. Risk diagnosis c. Possible diagnosis d. Wellness diagnosis

ANS: B When patients have the potential or risk for a problem to develop, a risk diagnosis is written. These diagnoses are two part statements such as Risk for falls related to unsteady gait. An actual diagnosis consists of a NANDA diagnostic label, contributing factor (if known), and defining characteristics such as signs and symptoms. A possible nursing diagnosis identifies a problem that may occur, but the assembled data are insufficient to confirm it. A wellness diagnosis applies to individuals for whom an enhanced level of wellness is possible.

20. In which way(s) is nursing diagnosis different from a medical diagnosis? (Select all that apply.) a. Statement of the patients alterations in structure and functions b. Description of the patients ability to function in relation to impairment c. Tend to remain the same throughout the course of illness or recovery from injury d. Varies depending on patients state of recovery e. Based on research done by nurses f. Conditions can be accurately identified by nursing assessment methods

ANS: B, D, E, F Nursing diagnoses, as exemplified by the NANDA I taxonomy, are statements about the patients ability to function in relation to an illness or injury, vary with the patients state of recovery, are based on research done by nurses, and can be determined based on nursing assessment methods. Nursing diagnoses do not include statements of the patients alterations in structure and function and do not remain the same throughout the course of illness or recovery from injury.

8. Which is an example of an interdependent nursing action? a. Assess lung sounds every 4 hours. b. Educate the patient about the prescribed medication. c. Administer Demerol 50 mg intramuscularly (IM) every 4 hours PRN. d. Encourage the patient to express feelings.

ANS: C Administer Demerol 50 mg IM every 4 hours PRN requires the nurse to follow the parameters of the order, yet use nursing judgment to determine how often the medication is to be administered therefore, it is an interdependent nursing action. Assessing lung sounds, educating the patient about medication, and encouraging the patient to express feelings are independent nursing actions

11. What is the priority nursing diagnosis for an older adult with diabetes who is hospitalized for pneumonia? a. Deficient knowledge related to lack of information about diabetic medication b. Risk for falls related to weakness c. Impaired gas exchange related to decreased pulmonary ventilation d. Imbalanced nutrition: more than body requirements related to obesity

ANS: C Airway is the first priority in a needs assessment (ABCs = airway, breathing, circulation). Medication, weakness, and nutrition are less of a priority than the patients respiratory status.

4. Which statement regarding nursing diagnoses is accurate? a. Nursing diagnoses remain the same for as long as the disease is present. b. Nursing diagnoses are written to identify disease states. c. Nursing diagnoses describe patient problems that nurses treat. d. Nursing diagnoses identify causes related to illness.

ANS: C Diagnostic statements identify problems a nurse is independently able to treat within the scope of professional practice. Nursing diagnoses vary with the changing condition of the patient. The response patterns are unique to the patient and are not disease specific. Nursing diagnoses describe the patients human response pattern.

14. A patient is experiencing adverse effects of a medication. Which information obtained by the nurse is subjective? a. Cough b. Edema c. Nausea d. Tachycardia

ANS: C Nausea is a symptom for which only the person experiencing it can provide the information. Cough is heard by the nurse. Edema is measured and seen by the nurse. Tachycardia is assessed by the nurse.

13. When a nursing diagnosis statement is written, who or what directs the nurse to identify appropriate nursing interventions? a. Other nurses on staff who have experience with the diagnoses b. The patient and family who have an interest in the outcome c. The etiologies of the problems identified in the nursing diagnoses d. The medical staff who have more expertise than the nurses

ANS: C Nursing actions are suggested by the etiologies of the problems identified in the nursing diagnoses and are used to implement plans. Nursing actions are not suggested by other nurses, the patient and family, or by the medical staff.

17. Which statement best describes the planning phase of the nursing process? a. Administer insulin subcutaneously (subcut) in the abdominal area. b. Patient is at high risk for falls related to hypotension. c. The patient will state the expected adverse effects of medication by the end of the teaching session. d. Itching has resolved medication given is effective.

ANS: C The patient will state the expected adverse effects of medication by the end of the teaching session is an example of a goal statement that is developed in the planning phase. Administration of insulin subcut is an example of the implementation phase. Noting a high risk for falls related to hypotension is an example of the second phase or nursing diagnosis. Stating that the medication given is effective is an example of the evaluation phase.

1. What is the primary purpose of the nursing assessment? a. Identifying underlying pathologic conditions b. Assisting the physician in identifying medical conditions c. Determining the patients mental status d. Exploring patient responses to health problems

ANS: D A nursing assessment is done to identify the patients response to health problems. During the nursing assessment phase, a comprehensive information base is developed through a physical examination, nursing history, medication history, and professional observation. Identifying underlying pathologic conditions and assisting the physician in identifying medical conditions is not part of the nursing process. Determining the patients mental status is one part of the nursing assessment, but it is not the primary purpose.

3. Which task is included in the assessment step of the nursing process? a. Establishing patient goals/outcomes b. Implementing the nursing care plan (NCP) c. Measuring goal/outcome achievement d. Collecting and communicating data

ANS: D Data are collected and communicated in the assessment phase of the nursing process. Establishing goals is the function of planning. Implementing the NCP is the function of implementation. Measuring outcome achievement is the function of evaluation.

9. What is the nurses primary source of information when obtaining a patient history? a. The physician b. The patient record c. The family d. The patient

ANS: D The focus of the nursing process is the patient. Although family members contribute to the nursing history, this information is secondhand. It is important that the nurse continue to assess patient data for validation of this information. The physician is not to be relied on to provide information about a complete patient history. The patient record reflects only recorded past information and not current input that may be relevant. The family may provide information about a patient history if the patient is unable to provide it, but the information is subject to interpretation by someone other than the patient.

7. Which outcome statement identified by the nurse is written correctly? a. After surgery, patient will express acceptance of loss of breast. b. Patient will die with dignity. c. At the end of the shift, the nurse will determine whether the patient is more comfortable. d. Within the next 8 hours, urine output will be greater than 30 mL/hr.

ANS: D The statement, Within the next 8 hours, urine output will be greater than 30 mL/hr is patient oriented, realistic, and measurable, and has an appropriate time frame.

2. What is the basis of the NANDA I taxonomy? a. Functional health patterns b. Human response patterns c. Basic human needs d. Pathophysiologic needs

ANS: B The NANDA I taxonomy identifies human response patterns. Functional components of health patterns are limited to activity, fluid volume, nutrition, self care, and sensory perception. Basic human needs comprise less than merely health patterns. Pathophysiologic needs are not part of the scope of NANDA I.