Which of the following will determine nursing interventions for a client on medication Quizlet

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The nurse is reviewing the steps of the nursing process with a student. The nurse knows that the student understands the teaching when the student correctly lists which of the following as the correct order of the nursing process?

1. Establish nursing diagnosis, assessment, intervene, collaborate, evaluation
2. Establish goals, assessment, intervention, planning, communication
3. Assessment, establish nursing diagnosis, planning, interventions, evaluation
4. Assessment, planning, establish objectives, communication, evaluation

During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. What is the correct order of steps for this?

1. Modify care plan as needed.
2. Decide if the nursing interventions remain appropriate.
3. Reassess the patient.
4. Compare assessment findings to validate existing nursing diagnoses.

A. 2, 1, 3, 4
B. 3, 4, 2, 1
C. 4, 3, 2, 1
D. 3, 4, 1, 2

1, 2, 4, 5

During counseling, the nurse must counsel the patient to accept the change in health status. Once the change has been accepted, the patient can start taking care of himself or herself. Counseling involves emotional, psychological, intellectual, and spiritual support, not just emotional and psychological support. Counseling helps in managing stress and developing interpersonal relationships. A patient and family who need nursing counseling have normal adjustment difficulties and may be upset or frustrated, but they are not always psychologically disabled.

1. Which of the following are correct statements regarding nursing diagnoses? (Select all that apply.)

A. They identify the medical problem experienced by the patient.

B. They are identified for the patient by the nurse.

C. They identify the patient's response to actual or potential health and life processes.

D. They assist in determining nursing interventions.

E. They remain the same throughout the patient's health care encounter to ensure continuity of care.

C & D

Rationale: NANDA classifies a nursing diagnosis as a clinical judgment about individual, family, or community responses to actual or potential health or life processes. Nursing diagnoses provide the basis for the selection of nursing interventions to achieve client outcomes based on the nursing diagnoses.

Options A, B, and E are incorrect. Nursing diagnoses are not the same as medical diagnoses and are not established solely by the nurse but in collaboration with the client. They focus on the client's needs, not the nurse's needs. Nursing diagnoses do not always remain the same throughout the client's health care encounter but are evaluated for continuing appropriateness as part of the evaluation phase of the nursing process. Cognitive Level: Analyzing.
Nursing Process: Nursing Diagnosis.

Client Need: Health Promotion and Maintenance. NANDA-I © 2012

2. Which of the following represents an appropriate outcome established during the planning phase?

A. The nurse will teach the patient to recognize and respond to adverse effects from the medication.

B. The patient will demonstrate self-administration of the medication, using a preloaded syringe into the subcutaneous tissue of the thigh, prior to discharge.

C. The nurse will teach the patient to accurately prepare the dose of medication.

D. The patient will be able to self-manage his disease and medications.

B

Rationale: The outcome statement includes what action the client needs to achieve (self-administration of the medication), the expected performance (using a preloaded syringe into the subcutaneous tissue of the thigh), and when it will be accomplished (by discharge).

Options A, C, and D are incorrect. These statements do not contain the required components of an outcome statement: actions required by the client, under what circumstances, the expected performance, and the specific time frame in which the client will accomplish that performance.

Cognitive Level: Analyzing.

Nursing Process: Planning.

Client Need: Health Promotion and Maintenance.

3. A 15-year-old adolescent with a history of diabetes is treated in the emergency department for complications related to skipping her medication for diabetes. She confides in the nurse that she deliberately skipped some of her medication doses because she did not want to gain weight and she is afraid of needle marks. Before establishing a diagnosis of "Noncompliance," what should the nurse assess?

A. Whether the patient received adequate teaching related to her medication and expresses an understanding of that teaching

B. Whether the patient was encouraged to skip her medication by a family member or friend

C. Whether the patient is old enough to understand the consequences of her actions

D. Whether the provider will write another prescription because the patient refused to take the medication the first time

A

Rationale: Before establishing a diagnosis of "Noncompliance," the nurse must ensure that the client was properly educated about the medication and has made an educated decision not to take it. It is vital to explore all possible factors leading to the noncompliance before establishing this diagnosis. From this client's statements, it is possible that she does not fully understand why the medication was prescribed and the harm of not taking it.

Options B, C, and D are incorrect. Although it is not known whether family members or friends had an impact on her decision, an educated client would understand the consequences of a choice to forego medication. Family members should also be included in the client education if there is a concern that the client is not old enough to fully understand. Whether the provider will write a new prescription does not factor into the need for adequate client education.

Cognitive Level: Analyzing.

Nursing Process: Nursing Diagnosis.

Client Need: Health Promotion and Maintenance.

4. Which factor is most important for the nurse to assess when evaluating the effectiveness of a patient's drug therapy?

A. The patient's promise to comply with drug therapy

B. The patient's satisfaction with the drug

C. The cost of the medication

D. Evidence of therapeutic benefit from the medication

D

Rationale: Once pharmacotherapy is initiated, ongoing assessment is conducted to determine the presence of therapeutic effects or adverse effects. The lack of therapeutic effects should be cause for a re-evaluation of the medication for appropriateness.

Options A, B, and C are incorrect. The client's promise to take the medication may involve many factors that affect the willingness to take medication. Although cost of the medication and the client's satisfaction may factor into a willingness to take the drug, they are of less importance than the fact of whether the drug is therapeutic and treating the condition it is prescribed for.

Cognitive Level: Analyzing.

Nursing Process: Assessment.

Client Need: Health Promotion and Maintenance.

5. Which method may offer the best opportunity for patient teaching?

A. Providing detailed written information when the client is discharged

B. Providing the patient with Internet links to conduct research on drugs

C. Referring the patient to external health care groups that provide patient education, such as the American Heart Association

D. Providing education about the patient's medications each time the nurse administers the drugs

D

Rationale: Every nurse-patient interaction can present an opportunity for teaching and each time the nurse administers the client's medications is such an opportunity. Small portions of education given over time are often more effective than large amounts of information given on only one occasion.

Options A, B, and C are incorrect. Providing written materials, accurate Internet site referral, and community health group referrals are valid measures to support a client's need for education but they do not take the place of the nurse-client relationship and the frequent and continuous education provided by the nurse during care.

Cognitive Level: Applying.

Nursing Process: Implementation.

Client Need: Health Promotion and Maintenance.

6. During the evaluation phase of drug administration, the nurse completes which responsibilities?

A. Prepares and administers drugs correctly

B. Establishes goals and outcome criteria related to drug therapy

C. Monitors the patient for therapeutic and adverse effects

D. Gathers data in a drug and dietary history

C

Rationale: During the evaluation phase, the nurse assesses whether the therapeutic effects of the drug were achieved as well as whether adverse effects were prevented or kept to acceptable levels.

Options A, B, and D are incorrect. Preparing and administering drugs correctly is a component of the implementation phase. Establishing goals and outcomes is a component of the planning phase and gathering a drug and dietary history occurs during assessment.

Cognitive Level: Analyzing.

Nursing Process: Evaluation.

Client Need: Physiological Integrity.

1. A 67-year-old patient has been diagnosed with a type of anemia that requires monthly injections of vitamin B12. He is learning how to give himself the injections at home and does not have any visual or dexterity impairments. The nurse has taught and reviewed how to draw the solution out of the medication vial into the syringe and is now working on the appropriate injection technique. Write an outcome statement for this patient.

Sometimes several outcome statements may be needed if the complexity of the task has multiple parts, such as learning to give an injection. For this patient who has already mastered the preparation of the medication, an outcome statement would be: The patient will demonstrate the injection of vitamin B12 into the anterolateral thigh muscle areas before leaving the office at this appointment.

2. While evaluating the therapeutic effects of a medication prescribed for the patient with asthma, the nurse notes that the goal has been only "partially met" because the patient continues to have some wheezing, despite taking the medication for two days. What should the nurse do next?

If the goal was partially met, the nurse must rely on further assessment data, further assessment information provided by the health care provider if available, and the nurse's own clinical knowledge and skills to determine the next appropriate step. If the patient is moving toward the goal, the nurse may need to continue the intervention (e.g., administration of the medication) for a longer time, or somehow modify the intervention (e.g., discuss the nurse's assessment with the health care provider for further orders) to completely resolve the problem.

3. A nursing student is assigned to a nurse preceptor who is administering oral medications. The student notes that the preceptor administers the drugs safely but routinely fails to offer the patient information about the drug being administered. Identify the information that the nurse should teach the patient during medication administration

When the nurse administers medications, it presents an opportunity to teach the patient important information about the drugs including the name of the drug(s), the reason it has been ordered, potential side effects to be observant for, and when the patient should call the provider (e.g., for side effects not easily managed at home or if there are no therapeutic effects noted after a certain length of time). If the drug has special administration requirements such as taking on an empty stomach or parenteral use, the nurse also teaches patients and their families or caregivers the appropriate administration techniques, followed by teach-back if applicable.

When performing an assessment about medication drug history should include Which?

A good medication history should encompass all currently and recently prescribed drugs, previous adverse drug reactions including hypersensitivity reactions, any over-the counter medications, including herbal or alternative medicines, and adherence to therapy. 2.

Which information is essential for the nurse to collect when reviewing a clients medication list?

Components of a Medication Order.
Name of the patient..
Age or date of birth..
Date and time of the order..
Drug name..
Dose, frequency, and route..
Name/Signature of the prescriber..
Weight of the patient to facilitate dose calculation when applicable. ... .
Dose calculation requirements, when applicable..

Which among the following are activities involved in the diagnosis phase of the nursing process?

The diagnosis phase of the nursing process involves three main steps: data analysis, identification of the patient's health problems, risks, and strengths, and formation of diagnostic statements.

Which of the following is an unexpected effect of the drug is known as a N ):?

Any unwanted or unexpected effects of a medicine are called side effects. They are also sometimes called adverse effects or adverse reactions. Side effects can also occur with interactions with other medicines or food.