C HAPTER 04: T HE N URSING P ROCESS AND
P HARMACOLOGY
Willihnganz: Clayton’s Basic Pharmacology for Nurses, 19th Edition
MULTIPLE CHOICE
1. What is the nurse’s primary source of information when obtaining a patient
history?
a. The physician
b. The patient record
c. The famil y
d. The patient
ANS: D
The focus of the Nursing Process is the patient. Although famil y members
contribute to the nursing history, this information is second hand. It is
important that the nurse contin ue 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 onl y recorded past
information and not current input that may be relevan t. The famil y 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.
DIF: Cognitive Level: Knowledge REF: p. 39 | p. 40 OBJ: 2
NAT: NCLEX Client Needs Category: Safe, Effective Care
Environment
TOP: Nursing Process Step: Assessment CON: Clinical Judgment
,2. 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. Patient’s weight
b. Patient’s understanding of the 1500 calorie diet
c. Nurse’s feelings about obese patients
d. Healthcare agency’s abilit y to provide the prescribed diet
ANS: B
When goals are not met, the nurse must reassess the pa tient’s 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 nurse’s feelings should not be a factor in the assessment.
The agency’s abilit y to provide the prescribed diet should have been
determined before implementation of the plan.
DIF: Cognitive Level: Anal ysis REF: p. 42 | p. 43 OBJ: 1 | 6
NAT: NCLEX Client Needs Category: Safe, Effective Care
Environment
TOP: Nursing Process Step: Evaluation
CON: Clinical Judgment | Patient Education
3. What is a critical care pathway?
a. Nursing care plan for a patient in a critical care unit
b. Standardized care plan derived from best practice patterns
c. Care plan that has been critiqued by a qualit y improvement officer
d. Care plan based on measurable goals and outcomes
, ANS: B
A critical care pathwa y 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 t ype 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 qualit y improvement officer is not a critical care
pathway. All good care plans are based on measurable goals and outcomes.
DIF: Cognitive Level: Knowledge REF: p. 45 OBJ: 2
NAT: NCLEX Client Needs Category: Physiological Integrit y
TOP: Nursing Process Step: Planning CON: Clinical Judgment
4. When a nursing diagnosis statement is written, who or what directs the
nurse to identif y 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 m ore 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 famil y, or by th e medical staff.
DIF: Cognitive Level: Comprehension REF: p. 42 OBJ: 6
NAT: NCLEX Client Needs Category: Physiological Integrit y
TOP: Nursing Process Step: Planning CON: Clinical Judgment
5. Which information obtained by the nurse is subjective when a pa tient
experiences adverse effects of a medication?
P HARMACOLOGY
Willihnganz: Clayton’s Basic Pharmacology for Nurses, 19th Edition
MULTIPLE CHOICE
1. What is the nurse’s primary source of information when obtaining a patient
history?
a. The physician
b. The patient record
c. The famil y
d. The patient
ANS: D
The focus of the Nursing Process is the patient. Although famil y members
contribute to the nursing history, this information is second hand. It is
important that the nurse contin ue 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 onl y recorded past
information and not current input that may be relevan t. The famil y 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.
DIF: Cognitive Level: Knowledge REF: p. 39 | p. 40 OBJ: 2
NAT: NCLEX Client Needs Category: Safe, Effective Care
Environment
TOP: Nursing Process Step: Assessment CON: Clinical Judgment
,2. 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. Patient’s weight
b. Patient’s understanding of the 1500 calorie diet
c. Nurse’s feelings about obese patients
d. Healthcare agency’s abilit y to provide the prescribed diet
ANS: B
When goals are not met, the nurse must reassess the pa tient’s 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 nurse’s feelings should not be a factor in the assessment.
The agency’s abilit y to provide the prescribed diet should have been
determined before implementation of the plan.
DIF: Cognitive Level: Anal ysis REF: p. 42 | p. 43 OBJ: 1 | 6
NAT: NCLEX Client Needs Category: Safe, Effective Care
Environment
TOP: Nursing Process Step: Evaluation
CON: Clinical Judgment | Patient Education
3. What is a critical care pathway?
a. Nursing care plan for a patient in a critical care unit
b. Standardized care plan derived from best practice patterns
c. Care plan that has been critiqued by a qualit y improvement officer
d. Care plan based on measurable goals and outcomes
, ANS: B
A critical care pathwa y 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 t ype 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 qualit y improvement officer is not a critical care
pathway. All good care plans are based on measurable goals and outcomes.
DIF: Cognitive Level: Knowledge REF: p. 45 OBJ: 2
NAT: NCLEX Client Needs Category: Physiological Integrit y
TOP: Nursing Process Step: Planning CON: Clinical Judgment
4. When a nursing diagnosis statement is written, who or what directs the
nurse to identif y 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 m ore 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 famil y, or by th e medical staff.
DIF: Cognitive Level: Comprehension REF: p. 42 OBJ: 6
NAT: NCLEX Client Needs Category: Physiological Integrit y
TOP: Nursing Process Step: Planning CON: Clinical Judgment
5. Which information obtained by the nurse is subjective when a pa tient
experiences adverse effects of a medication?
