Ch. 2 Nursing Process & Client Teaching

Question 0

Why is assessment particularly important in the nursing process?

Answer 0

The data provided by the assessment form the basis on which care is planned, implemented, and evaluated.

Question 1

What are the 4 phases of the nursing process?

Answer 1

1. Assessment (including nursing diagnosis)
2. Planning
3. Implementation
4. Evaluation

Question 2

Which two types of information does data collection involve?

Answer 2

1. Subjective

2. objective

Question 3

Which 5 components are reflective of subjective data?

Answer 3

1. Current health history, including problems swallowing
2. Client symptoms, as described by the client
3. Current medications
4. Past health history
5. Client’s environment

Question 4

Which 11 items should be addressed when assessing a client’s current medications?

Answer 4

1. Dosage, frequency, route, prescribing healthcare provider, if any
2. Client knowledge about drug and its side effects and for what diagnosis and symptoms client is taking a drug
3. Client expectation and perception of drug effectiveness
4. Client knowledge about what effects or drug reactions to report to healthcare provider
5. Client adherence with regimen and reasons for deviations. Are deviations based on valid data/rationale and clinically sound?
6. Drug allergies or reactions book past and present; also food and dye intolerance and reactions
7. OTC drugs
8. Herbal remedies
9. Street drugs. If used, what is the frequency of use?
10. Alcohol consumption
11. Smoking or tobacco history

Question 5

Which 3 items should be addressed while assessing a client’s past health history?

Answer 5

1. Past illnesses, major injuries, and drug therapy, including reactions
2. Mental status
3. Medication saved from previous use; how how stored; expiration date

Question 6

Which 12 items should be addressed while assessing a client environment?

Answer 6

1. Client’s language and communication needs
2. Does client read and follow instructions from healthcare provider in the pharmacy?
3. Client knowledge of specific drug storage requirements, if any
4. Availability, willingness, and psychomotor ability to administer or assist in the administration of medication. [This information is essential for third-party payment for continued home visit or for admission to an extended care facility.]
5. Household members, neighbors, friends, and their roles; ages of household members
6. Learning style preferences
7. Readiness to learn
8. Activities of daily living (ADLs) capabilities
9. Dietary patterns, cultural and economic influences, safety
10. Financial resources or limitations [drugs can be expensive]
11. Mental status

Question 7

Which 4 components are reflective of objective data?

Answer 7

1. Limitations in gross and fine motor control, hand joint range of motion, and decreased muscle strength can interfere with clients ability to open medication containers. Visual impairment can limit the clients ability to read labels and correctly measured dosages.
2. Laboratory test results
3. Diagnostic studies
4. Physical/health assessment

Question 8

What is important to record baseline data during an assessment?

Answer 8

Baseline data are essential for future comparisons.

Question 9

What should data collection focus on?

Answer 9

Symptoms and those organs most likely to be affected by drug therapy.

Question 10

Enhancing client adherence with the drug therapy regimen is an essential component of what?

Answer 10

Health teaching

Question 11

The client and family response to which 3 questions will provide the nurse with the critical information needed to each client’s teaching situation?

Answer 11

1. What things help you take your medication as prescribed?
2. What things prevent you from taking your medication as prescribed?
3. What would you do if you forgot to take a dose of medication?

Question 12

List 12 frequently cited factors for nonadherence to drug regimens.

Answer 12

1. Forgetfulness
2. Knowledge deficit
3. Side effects
4. Low self-esteem
5. Depression
6. Lack of trust in the healthcare system
7. Family problems
8. Language barriers
9. Hi cost of medications
10. Anxiety
11. Value systems (religious and other)
12. Lack of motivation

Question 13

List 8 nursing diagnoses related to drug therapy.

Answer 13

1. Pain (acute or chronic) related to hesitancy in taking prescribed pain medications because of fear of addiction.
2. Ineffective health maintenance related to not having recommended preventive care.
3. Ineffective protection related to the effects of anticoagulant medication on clotting mechanism
4. Noncompliance related to forgetfulness
5. Risk for injury related to side effects of drug
6. An ineffective therapeutic regimen
   management related to lack of finances or health care coverage to purchase medications.
7. Therapeutic regimen management, readiness for enhanced
8. Readiness for enhanced knowledge

Question 14

Effective goalsetting has which 6 qualities?

Answer 14

1. Client centered; clearly states the expected change
2. Acceptable to both client and nurse (dependent on client’s decision-making ability)
3. Realistic and measurable
4. Shirt with other healthcare providers
5. Realistic deadlines
6. Identifies components for evaluation

Question 15

Which aspect of client teaching is paramount and should be presented first?

Answer 15

Readiness

Question 16

Which 5 headings might be included in an outline related to pharmacotherapeutics?

Answer 16

1. General Information
2. Self administration
3. Diet
4. Side effects
5. Cultural considerations