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Nursing Process Approach, 11th Edition by Linda
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E. McCuistion Chapter 1-58 A+ Guide revised
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,Chapter01:The NursingProcessandPatient-Centered Care
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McCuistion: Pharmacology: A Patient-Centered Nursing Process Approach, 11th Edition
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MULTIPLE ssCHOICE
1. Ass5-year-old sschild sswith sstype ss1 ssdiabetes ssmellitus sshas sshad ssrepeated sshospitalizations ssfor
ssepisodes ssof sshyperglycemia. s s The s s parents s s tell s s the s s nurse s s that s s they sscan‘t s s keep s s track s s of
ss everything s s that s s has s s to ssbe ssdone ssto sscare ssfor sstheir sschild. ssThe ssnursessreviews ssmedications,
ssdiet, ssand sssymptom ssmanagement sswith ssthe ssparents ssand ssdraws ssup ssa ssdaily sschecklist ssfor ssthe
ssfamily ssto ssuse. ssThese ssactivities ssare sscompleted ssin sswhich ssstep ssof ssthe ssnursing ssprocess?
a. Recognizing cues ss(assessment)
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b. Analyzesscues ss&ssprioritizesshypothesis ss(analysis)
c. Generatesolutions ss(planning)
d. Takeaction ss(nursinginterventions)
ANS: s s D
Takingaction ssthrough ssnursing interventions ssiswheresthesnursessprovidessspatient sshealth ssteaching,
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ssdrug ssadministration, sspatient sscare, ssand ssother ssinterventions ssnecessary ssto ssassist ssthe sspatient
ssin ssaccomplishing ssexpected ssoutcomes.
DIF: Cognitive ssLevel: ssUnderstanding
ss(Comprehension) ssTOP: s s Nursing ssProcess: ssNursing
ssIntervention
MSC: s s NCLEX:ssManagement ssofssClientssCare
2. Allof ssthe ssfollowing sswould ssbessconsidered s s subjective ssdata, ssEXCEPT:
a. Patient-reportedhealth sshistory
b. Patient-reportedsssigns ssandsssymptoms ssofsstheirssillness
c. Financial ssbarriers ssreportedssbyssthespatient‘s sscaregiver
d. Vitalssigns ssobtained ssfrom ssthessmedical ss record
ANS: s s D
Subjective ssdata ssisssbased ssonsswhat sspatients ssor ssfamily ssmembers sscommunicate s s tossthe ssnurse.
ssPatient- ssreported sshealth sshistory, sssigns ssand sssymptoms, ssand sscaregiver ssreported ssfinancial
ssbarriers sswould ssbe ssconsidered sssubjective ssdata. ssVital sssigns ssobtained ssfrom ssthe ssmedical
ssrecord sswould ssbe ssconsidered ssobjective ssdata.
DIF: Cognitive ssLevel: ssUnderstanding ss(Comprehension) TOP: ssNursingsProcess:sPlanning
ssMSC: s s NCLEX: ssManagement ssof ssClient ssCare
3. Thessnursesis ssusingssdata sscollected ssto ssdefine ssassset ssof ssinterventions ssto ssachieve ssthe ssmost
desirable ssoutcomes. ssWhich ssof ssthe ssfollowing sssteps ssis ssthe ssnurse ssapplying?
ss
a. Recognizing cues ss(assessment)
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b. Analyzesscues ss&ssprioritizesshypothesis ss(analysis)
c. Generatesolutions ss(planning)
d. Takeaction ss(nursinginterventions)
ANS: s s C
When ssgenerating sssolutions ss(planning), ssthe ssnurse ssidentifies ssexpected ssoutcomes ssand ssuses ssthe
sspatient‘s ssproblem(s) ssto ssdefine ssa ssset ssof ssinterventions ssto ssachieve ssthe ssmost ssdesirable
ssoutcomes. ssRecognizing sscues ss(assessment) ssinvolves ssthe ssgathering ssof sscues ss(information)
ssfrom ssthe sspatient ssabout s s their s s health s s and s s lifestyle s s practices, s s which s s are s s important s s facts
s s that s s aid s s the s s nurse s s in ssmaking s s clinical sscare ssdecisions. ssPrioritizing sshypothesis ssis ssused ssto
ssorganize ssand ssrank ssthe sspatient ssproblem(s) ssidentified. ssFinally, sstaking ssaction ssinvolves
ssimplementation ssof ssnursing ssinterventions ssto ssaccomplish ssthe ssexpected ssoutcomes.
,DIF: Cognitive ssLevel: ssUnderstanding ss(Comprehension)
, TOP: s s Nursing Process: ssNursing Intervention
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ssMSC: s s NCLEX: ssManagement ssof ssClient
ssCare
4. The ssnurse ssis ss preparing ssto s s administer ssa s s medication s s and s s reviews s s the s s patient‘s
s s chart s s for ssdrug ssallergies, ssserum sscreatinine, ssand ssblood ssurea ssnitrogen ss(BUN) sslevels.
ssThe ssnurse‘s ssactions ssare ssreflective ssof sswhich ssof ssthe ssfollowing?
a. Recognizing cues ss(assessment)
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b. Analyzesscues ss&ssprioritizesshypothesis ss(analysis)
c. Takeaction (nursingsinterventions)
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d. Generatesolutions ss(planning)
ANS: s s A
Recognizingsscues ss(assessment)sinvolves ssgathering sssubjectivesandssobjectivesinformation ssaboutssthe
sspatient ssand ssthe ssmedication. ssLaboratory ssvalues ssfrom ssthe sspatient‘s sschart sswould ssbe
ssconsidered sscollection ssof ssobjective ssdata.
DIF: Cognitive ssLevel: ssUnderstanding (Comprehension)
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TOP: Nursing Process: s s Assessment
cc MSC: s s NCLEX:ssManagement ssofssClient ssCare
5. Whichof ssthe ssfollowing sswould ssbesscorrectly sscategorized s s as ssobjective ssdata?
a. Alist ssof ssherbal sssupplements s s regularlyssused ssprovided ssbyssthe sspatient.
b. Lab ssvalues ssassociated sswith ssthesdrugs ssthe sspatient ssis sstaking.
c. The ages ssand ssrelationship ssofssall sshousehold ssmembers ssto ssthesspatient.
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d. Usual ssdietarypatterns ss and ssfood ssintake.
ANS: s s B
Objectivessdata ssaresmeasured ssandssdetected ssbysanotherssperson ssand sswould ssincludesslabsvalues. ssThe
ssother ssexamples ssare sssubjective ssdata.
DIF: Cognitive ssLevel: ssUnderstanding (Comprehension)
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TOP: Nursing Process: s s Assessment
cc MSC: s s NCLEX: ssManagement ssofssClient ssCare
6. The ssnurse ssreviews ssa sspatient‘s ssdatabase ssand sslearns ssthat ssthe sspatient sslives ssalone, ssis
forgetful, ssand ssdoes ssnot sshave ssan ssestablished ssroutine. ssThe sspatient sswill ssbe sssent sshome sswith
ss
ssthree ssnew ssmedications ssto ssbe sstaken ssat ssdifferent sstimes ssof ssthe ssday. ssThe ssnurse ssdevelops ssa
ssdailyssmedication sschart ssand ssenlists ssa ssfamily ssmember ssto ssput ssthe sspatient‘s sspills ssin ssa sspill
ssorganizer. ssThis ssis ssan ssexample ssof sswhich sselement ssof ssthe ssnursing ssprocess?
a. Recognizing cues ss(assessment)
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b. Analyzesscues ss&ssprioritizesshypothesis ss(analysis)
c. Takeaction (nursingsinterventions)
cc