Chapter 4

21. After teaching a group of nursing students about nursing diagnoses, the instructor determines that the teaching was successful when the students identify which of the following as most useful related to the nursing diagnoses developed by the North American Nursing Diagnosis Association (NANDA)? A) Identifying patient problems related to drug therapy B) Classifying the patients according to their age groups C) Categorizing the drugs based on their therapeutic actions D) Identifying the expected outcomes of treatments given

Ans: A

24. A nurse is providing care to a patient who has been admitted to the health care facility. When administering drugs to this patient, which of the following would be most important for the nurse to do before administering a drug to the patient? A) Review the subjective and objective data. B) Provide the basis for the selection of nursing interventions. C) Review the related nursing diagnosis. D) List the potential goals to be achieved by the patient.

Ans: A

25. A nurse who has been caring for a patient determines that the plan has been successful based on which of the following? A) Expected outcomes are accomplished. B) Patient does not experience anxiety during therapy. C) Patient is better able to communicate with the nurse. D) Subjective and objective data are successfully obtained.

Ans: A

28. After administering a prescribed medication for pain relief, the nurse is evaluating the patient's response to therapy. Which of the following would the nurse document as objective data? A) Patient identifies a pain rating of 3 out of 10. B) Patient states that pain is much less. C) Patient's wife reports the patient was moaning in his sleep. D) Patient complains of feeling sleepy after taking the drug.

Ans: A

17. A patient is experiencing anxiety related to drug therapy. Which of the following would the nurse identify as a factor influencing the patient's level of anxiety? Select all that apply. A) Fear B) Severity of illness C) Patient's knowledge level D) Good comprehension of information E) Nonadherence to the plan

Ans: A, B, C

7. A nurse identifies a nursing diagnosis of Ineffective Self Health Management for a patient. Which of the following would the nurse identify as supporting this nursing diagnosis? Select all that apply. A) Visual impairment B) Forgetfulness C) Cognitive deficits D) Mobility issues E) Order entry error

Ans: A, B, C, D

2. Successful use of the nursing process requires which of the following? Select all that apply. A) Observation B) Teaching C) Practice D) Experience E) Updating

Ans: A, B, C, D, E

10. The nurse identifies a nursing diagnosis of Effective Self Health Management. Which of the following would the nurse use to support this nursing diagnosis? Select all that apply. A) Patient demonstrates ability to complete other tasks of daily living. B) Patient verbalizes desire to manage the medication regimen. C) Patient exhibits difficulty in ability to remember. D) Patient demonstrates ability to understand medication regimen. E) Patient states desire to learn about the prescribed medication.

Ans: A, B, D, E

16. A nurse is preparing a presentation for a group of patients requiring long-term medication therapy. The nurse expects to include common reasons for noncompliance with self-medication administration. Which of the following would the nurse be most likely to include? Select all that apply. A) Lack of knowledge about expected results B) Bothersome adverse effects C) Depression D) Anxiety E) Lack of information about the drug

Ans: A, B, D, E

4. When assessing a patient, which of the following would be involved? Select all that apply. A) Obtain a medication history. B) Obtain vital signs. C) Formulate nursing diagnoses. D) Ask about chief complaint. E) Determine therapeutic response.

Ans: A, B, D, E

12. A nurse identifies a nursing diagnosis of Ineffective Self Health Management. Which of the following would the nurse identify as supporting this nursing diagnosis? Select all that apply. A) Financial difficulty in obtaining the medication B) Lack of information about the drug therapy C) Ability to follow the prescribed medication schedule D) Ability to remember to take the drug regimen E) No therapeutic effect seen by patient

Ans: A, B, E

3. A nurse is assessing a patient. Which of the following would the nurse document as objective data? A) Temperature B) Heart rate C) Chief complaint D) Medication history E) Respiratory rate

Ans: A, B, E

15. After assessing a patient, the nurse identifies a nursing diagnosis of Deficient Knowledge related to drug self-administration. Which of the following would support this nursing diagnosis? Select all that apply. A) Inability to remember B) Lack of a college education C) Cognitive limitation D) Lack of interest in learning E) Lack of effectiveness of drug

Ans: A, C, D

29. A nurse is conducting an initial assessment of a patient. Which of the following would the nurse be most likely to address? Select all that apply. A) Use of over-the-counter drugs B) Effectiveness of pain relief C) History of allergies D) Auscultation of bowel sounds E) Understanding of newly prescribed medication

Ans: A, C, D

1. A nursing instructor is reviewing the nursing process with a group of nursing students. The instructor determines that the teaching was successful when the students identify which of the following as a phase? Select all that apply. A) Evaluation B) Documentation C) Analysis D) Assessment E) Planning

Ans: A, C, D, E

5. A nurse is completing an initial assessment of a patient. Which of the following would the nurse include in this assessment? Select all that apply. A) Allergy history B) Treatment response C) Occupational history D) Vital signs E) Pregnancy status

Ans: A, C, D, E

6. When preparing a teaching plan for a group of nursing students about drug administration and the nursing process, the instructor expects to include information about the most frequently used nursing diagnoses associated with drug administration. Which of the following would the instructor most likely include? Select all that apply. A) Noncompliance B) Ineffective Coping C) Deficient Knowledge D) Effective Self Health Management E) Ineffective Self Health Management

Ans: A, C, D, E

14. A nurse is developing a plan of care for a patient with a nursing diagnosis of Anxiety related to drug therapy. Which of the following would be important to include to foster a trusting and comfortable nurse-patient relationship? Select all that apply. A) Completing follow-up visits with the patient B) Sending a certified letter to the patient C) Calling the patient on the telephone D) Accompanying the patient to all physician appointments E) Encouraging the patient to express feelings and concerns

Ans: A, C, E

9. A nurse's taking a patient's blood pressure prior to administering a drug could be considered which of the following? Select all that apply. A) Assessment B) Implementation C) Subjective data D) Objective data E) Analysis

Ans: A, D

19. A nurse is evaluating a patient's understanding of his prescribed drug therapy regimen. Which of the following would the nurse use as part of this process? Select all that apply. A) Facial expressions B) "Yes" answers when asked about understanding C) Nodding of head through interaction D) Regimen being followed correctly E) Correct answers to questions asked

Ans: A, D, E

18. A nurse has collected all the relevant data and is now clustering the information to determine the patient's needs. The nurse is involved in which phase of the nursing process? A) Assessment B) Analysis C) Planning D) Implementation

Ans: B

20. A nurse caring for a patient is describing the steps for carrying out nursing activities that will assist in achieving patient goals. The nurse is in which phase of the nursing process? A) Assessment B) Planning C) Implementation D) Evaluation

Ans: B

26. A nurse is assigned to care for a patient with a cardiac disorder. During assessment, which of the following would be most appropriate to do when obtaining objective data related to the patient's condition? A) Review the patient's health history. B) Auscultate heart and lung sounds. C) Review the patient's family history. D) Inquire about the patient's eating habits.

Ans: B

30. The nurse identifies the nursing diagnosis of Noncompliance for a patient. Which of the following would the nurse most likely identify as the expected outcome? A) Patient verbalizes understanding of when to call the health care provider. B) Patient demonstrates ability to maintain adherence to prescribed drug therapy. C) Patient verbalizes desire to manage prescribed medication schedule. D) Patient identifies the reason for the prescribed drug therapy for his illness.

Ans: B

8. During the evaluation phase of the nursing process, which of the following would the nurse perform? Select all that apply. A) Independent nursing actions B) Collection of objective data C) Collection of subjective data D) Initial assessment E) Ongoing assessment

Ans: B, C, E

11. A nurse is developing a teaching plan for a patient who is receiving medications. Which of the following would the nurse expect to include in the teaching plan? Select all that apply. A) Chemical name of the drug B) Method for administering the drug C) Calculation for the prescribed dosage D) Expected effect of the drug E) Information to report to the primary health care provider

Ans: B, D, E

13. A nurse identifies a nursing diagnosis of Noncompliance. Which of the following would be most important for the nurse to determine? A) When the patient stopped taking the drug B) What adverse reactions the patient experienced C) What was the exact reason for stopping the drug D) Whether the patient's symptoms were relieved with the drug

Ans: C

23. A patient with a cardiac disorder is being discharged home. Which of the following would the nurse include when teaching the patient about administering the prescribed drug therapy at home? A) Composition of the drug B) Disorders treated using the drug C) Method of drug administration D) Contraindications of the drug

Ans: C

27. A nurse prepares to administer a prescribed medication and collects the necessary data for administering the drug. Based on this information, the nurse decides to withhold the drug and contact the prescriber. The nurse is in which phase of the nursing process? A) Assessment B) Planning C) Implementation D) Evaluation

Ans: C

31. After teaching a group of students about the nursing process, the instructor determines that the teaching was successful when the students identify goals and expected outcomes as components of which phase? A) Assessment B) Analysis C) Planning D) Implementation

Ans: C

22. A nurse is caring for a client diagnosed with a respiratory condition for which drug therapy has been prescribed. Which of the following would the nurse need to address when developing appropriate expected outcomes related to the drug therapy? A) Amount of time the patient will take to recover fully B) Amount of drugs the patient will require during the treatment C) Possible adverse reactions that could occur during the therapy D) Maximum level of wellness reasonably attainable for the patient

Ans: D