Deck 1: The Nursing Process and Patient-Centered Care
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Deck 1: The Nursing Process and Patient-Centered Care
1
The nurse reviews a patient's database and learns that the patient lives alone, is forgetful, and does not have an established routine. The patient will be sent home with three new medications to be taken at different times of the day. The nurse develops a daily medication chart and enlists a family member to put the patient's pills in a pill organizer. This is an example of which phase of the nursing process?
A) Assessment
B) Evaluation
C) Implementation
D) Planning
A) Assessment
B) Evaluation
C) Implementation
D) Planning
Implementation
2
Which assessment is categorized as objective data?
A) A list of herbal supplements regularly used
B) Lab values associated with the drugs the patient is taking
C) The ages and relationship to the patient of all household members
D) Usual dietary patterns and food intake
A) A list of herbal supplements regularly used
B) Lab values associated with the drugs the patient is taking
C) The ages and relationship to the patient of all household members
D) Usual dietary patterns and food intake
Lab values associated with the drugs the patient is taking
3
The nursing process is a five-step decision-making approach that includes all of the following steps, EXCEPT:
A) Assessment
B) Patient problem
C) Planning
D) Right Drug
A) Assessment
B) Patient problem
C) Planning
D) Right Drug
Right Drug
4
An adolescent patient who has acne is given a regimen of topical medications and an oral antibiotic that generally clears up lesions to fewer than 10 within 6 to 8 weeks. At a 2-month follow-up, the patient continues to have more than 25 lesions. The child's parent affirms that the child is using the medications as prescribed. Which evaluation statement is correct for this patient?
A) "Goal of fewer than 10 lesions in 6 to 8 weeks is not met."
B) "Goal that the medication will be effective is not met."
C) "Goal that the patient will take medications as prescribed is not met."
D) "Goal that the patient understands the medication regimen is not met."
A) "Goal of fewer than 10 lesions in 6 to 8 weeks is not met."
B) "Goal that the medication will be effective is not met."
C) "Goal that the patient will take medications as prescribed is not met."
D) "Goal that the patient understands the medication regimen is not met."
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5
A school-age child will begin taking a medication to be administered at 5 mL three times daily. The child's parent tells the nurse that, with a previous use of the drug, the child repeatedly forgot to bring the medication home from school, resulting in missed evening doses. What will the nurse recommend?
A) Asking the provider if the medication may be taken before school, after school, and at bedtime
B) Putting a note on the child's locker to encourage the child to take responsibility for medication administration
C) Asking the provider if 7.5 mL may be taken in the morning and 7.5 mL may be taken in the evening so that the correct amount is given daily
D) Taking the noon dose to school every day and giving it to the school nurse to administer
A) Asking the provider if the medication may be taken before school, after school, and at bedtime
B) Putting a note on the child's locker to encourage the child to take responsibility for medication administration
C) Asking the provider if 7.5 mL may be taken in the morning and 7.5 mL may be taken in the evening so that the correct amount is given daily
D) Taking the noon dose to school every day and giving it to the school nurse to administer
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6
A 5-year-old child with type 1 diabetes mellitus has had repeated hospitalizations for episodes of hyperglycemia. The parents tell the nurse that they can't keep track of everything that has to be done to care for their child. The nurse reviews medications, diet, and symptom management with the parents and draws up a daily checklist for the family to use. These activities are completed in which step of the nursing process?
A) Assessment
B) Planning
C) Implementation
D) Evaluation
A) Assessment
B) Planning
C) Implementation
D) Evaluation
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7
The nurse is developing a teaching plan for an elderly patient who will begin taking an antihypertensive drug that causes dizziness and orthostatic hypotension. Which patient problem documented by the nurse is appropriate for this patient?
A) Deficient knowledge related to drug side effects
B) Ineffective health maintenance related to age
C) Readiness for enhanced knowledge related to medication side effects
D) Risk for injury related to side effects of the medication
A) Deficient knowledge related to drug side effects
B) Ineffective health maintenance related to age
C) Readiness for enhanced knowledge related to medication side effects
D) Risk for injury related to side effects of the medication
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8
During a home visit, the nurse learns that a patient has not been taking their medications as prescribed. The patient reports having no insurance and tells the nurse that the drug is too expensive. After learning that there is no substitute medication, the nurse will perform which action next?
A) Assist the patient to apply for a patient-assist program.
B) Contact the pharmacy to request a reduction in the cost of the drug.
C) Determine the patient's annual income.
D) Give the patient the number of a charitable organization that may be able to help.
A) Assist the patient to apply for a patient-assist program.
B) Contact the pharmacy to request a reduction in the cost of the drug.
C) Determine the patient's annual income.
D) Give the patient the number of a charitable organization that may be able to help.
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9
A patient will be sent home with a metered-dose inhaler, and the nurse is providing teaching. Which is a correctly written goal for this process?
A) The nurse will demonstrate the correct use of a metered-dose inhaler to the patient.
B) The nurse will teach the patient how to administer medication with a metered-dose inhaler.
C) The patient will know how to self-administer the medication using the metered-dose inhaler.
D) The patient will independently administer the medication using the metered-dose inhaler at the end of the session.
A) The nurse will demonstrate the correct use of a metered-dose inhaler to the patient.
B) The nurse will teach the patient how to administer medication with a metered-dose inhaler.
C) The patient will know how to self-administer the medication using the metered-dose inhaler.
D) The patient will independently administer the medication using the metered-dose inhaler at the end of the session.
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10
The nurse is preparing to administer a medication and reviews the patient's chart for drug allergies, serum creatinine, and blood urea nitrogen (BUN) levels. The nurse's actions are reflective of which phase of the nursing process?
A) Assessment
B) Evaluation
C) Implementation
D) Planning
A) Assessment
B) Evaluation
C) Implementation
D) Planning
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11
The nurse is using data collected to set goals or expected outcomes and interventions that address the patient's problems. Which step of the nursing process is the nurse applying?
A) Assessment
B) Patient problem
C) Planning
D) Evaluation
A) Assessment
B) Patient problem
C) Planning
D) Evaluation
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12
A high-school student regularly forgets to use a twice-daily inhaled corticosteroid to prevent asthma flares and is repeatedly admitted to the hospital. The child's parent tells the nurse that the child has been told that forgetting to take the medication causes frequent hospitalizations. The nurse will:
A) encourage the child to take responsibility for taking the medication.
B) reinforce the need to take prescribed medications to avoid hospitalizations.
C) suggest putting the inhaler with the child's toothbrush to use before brushing teeth.
D) suggest that the child's parents administer the medication to increase compliance.
A) encourage the child to take responsibility for taking the medication.
B) reinforce the need to take prescribed medications to avoid hospitalizations.
C) suggest putting the inhaler with the child's toothbrush to use before brushing teeth.
D) suggest that the child's parents administer the medication to increase compliance.
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13
The nurse is developing a plan of care for a patient who has chronic lung disease and hypoxia. The patient has been admitted for increased oxygen needs above a baseline of 2 L/min. The nurse develops a goal stating, "The patient will have oxygen saturations of >95% on room air at the time of discharge from the hospital." What is wrong with this goal?
A) It cannot be evaluated.
B) It is not measurable.
C) It is not patient-centered.
D) It is not realistic.
A) It cannot be evaluated.
B) It is not measurable.
C) It is not patient-centered.
D) It is not realistic.
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14
An older patient must learn to administer a medication using a device that requires manual dexterity. The patient becomes frustrated and expresses lack of self-confidence in performing this task. Which action will the nurse perform next?
A) Ask the patient to keep trying until the skill is learned.
B) Provide written instructions with illustrations showing each step of the skill.
C) Schedule multiple sessions and practice each step separately.
D) Teach the procedure to family members who can administer the medication for the patient.
A) Ask the patient to keep trying until the skill is learned.
B) Provide written instructions with illustrations showing each step of the skill.
C) Schedule multiple sessions and practice each step separately.
D) Teach the procedure to family members who can administer the medication for the patient.
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15
A patient who is hospitalized for chronic obstructive pulmonary disease (COPD) wants to go home. The nurse and the patient discuss the patient's situation and decide that the patient may go home when able to perform self-care without dyspnea and hypoxia. This is an example of which phase of the nursing process?
A) Assessment
B) Evaluation
C) Implementation
D) Planning
A) Assessment
B) Evaluation
C) Implementation
D) Planning
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