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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:TheNursingProcessandPatient-CenteredCare
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McCuistion: Pharmacology: A Patient-Centered Nursing Process Approach, 11th Edition
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MULTIPLE CHOICE ss
1. A 5-year-old child with type 1 diabetes mellitus has had repeated hospitalizations for episodes
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of hyperglycemia. The parents tell the nurse that they can‘t keep track of everything
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that has to be done to care for their child. The nurse reviews medications, diet, and
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symptom management with the parents and draws up a daily checklist for the family to use.
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These activities are completed in which step of the nursing process?
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a. Recognizing cues (assessment) cc ss
b. Analyze cues &prioritize hypothesis (analysis) s ss s s ss
c. Generatesolutions (planning) ss
d. Takeaction (nursinginterventions) ss
ANS: s s D
Takingaction through nursing interventions iswherethenurse provides patient health teaching,
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drug administration, patient care, and other interventions necessary to assist the patient in
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accomplishing expected outcomes.
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DIF: Cognitive Level: Understanding ss ss
(Comprehension) TOP: Nursing Process: Nursing
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Intervention
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MSC: NCLEX: Management of Client Care
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2. Allof the following would be considered subjective data, EXCEPT:
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a. Patient-reportedhealth history ss
b. Patient-reportedsigns and symptoms of their illness s ss ss ss ss s
c. Financial barriers reported bythepatient‘s caregiver ss ss ss s s ss
d. Vitalsigns obtained from the medical record
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ANS: s s D
Subjective data is based on what patients or family members communicate to the nurse.
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Patient- reported health history, signs and symptoms, and caregiver reported financial barriers
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would be considered subjective data. Vital signs obtained from the medical record would
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be considered objective data.
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DIF: Cognitive Level: Understanding (Comprehension) ss ss ss TOP: NursingProcess:Planning
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MSC: NCLEX: Management of Client Care
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3. Thenurseis using data collected to define a set of interventions to achieve the most desirable
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outcomes. Which of the following steps is the nurse applying?
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a. Recognizing cues (assessment) cc ss
b. Analyze cues &prioritize hypothesis (analysis) s ss s s ss
c. Generatesolutions (planning) ss
d. Takeaction (nursinginterventions) ss
ANS: s s C
When generating solutions (planning), the nurse identifies expected outcomes and uses the
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patient‘s problem(s) to define a set of interventions to achieve the most desirable outcomes.
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Recognizing cues (assessment) involves the gathering of cues (information) from the patient
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about their health and lifestyle practices, which are important facts that aid the nurse
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in making clinical care decisions. Prioritizing hypothesis is used to organize and rank the
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patient problem(s) identified. Finally, taking action involves implementation of nursing
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interventions to accomplish the expected outcomes.
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,DIF: Cognitive Level: Understanding (Comprehension)
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, TOP: Nursing Process: Nursing Intervention
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MSC:
ss NCLEX: Management of Client
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Care
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4. The nurse is
ss preparing to administer a medication and reviews the patient‘s
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chart for drug allergies, serum creatinine, and blood urea nitrogen (BUN) levels.
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The nurse‘s actions are reflective of which of the following?
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a. Recognizing cues (assessment) cc ss
b. Analyze cues &prioritize hypothesis (analysis) s ss s s ss
c. Takeaction (nursinginterventions) cc s
d. Generatesolutions (planning) ss
ANS: s s A
Recognizingcues (assessment)involves gathering subjectiveandobjectiveinformation about the
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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) ss ss cc
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Client Care
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5. Whichof the following would be correctly categorized as objective data?
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a. Alist of herbal supplements regularly used provided bythe patient.
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b. Lab values associated with thedrugs the patient is taking.
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c. The ages and relationship of all household members to the patient.
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d. Usual dietarypatterns and food intake.
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ANS: s s B
Objective data aremeasured and detected byanotherperson and would include labvalues. The
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other examples are subjective data.
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DIF: Cognitive Level: Understanding (Comprehension) ss ss cc
TOP: Nursing Process: Assessment MSC: NCLEX: Management of Client Care
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6. The nurse reviews a patient‘s database and learns that the patient lives alone, is forgetful,
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and does not have an established routine. The patient will be sent home with three new
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medications to be taken at different times of the day. The nurse develops a daily medication
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chart and enlists a family member to put the patient‘s pills in a pill organizer. This is an
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example of which element of the nursing process?
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a. Recognizing cues (assessment) cc ss
b. Analyze cues &prioritize hypothesis (analysis) s ss s s ss
c. Takeaction (nursinginterventions) cc s