The nurse is writing a nursing diagnosis for a plan of care for a patient who has
been newly diagnosed with type 2 diabetes. Which statement reflects the
correct format for a nursing diagnosis?
A) Anxiety
B) Anxiety related to new drug therapy
C) Anxiety related to anxious feelings about dru...
NUR 206 Exam 1 Questions and Answers The nurse is w riting a nursing diagnosis for a plan of care for a patient who has been newly diagnosed with type 2 diabetes. Which statement reflects the correct format for a nursing diagnosis? A) Anxiety B) Anxiety related to new drug therapy C) Anxiety related to anxious feelings about drug therapy, as evidenced by statements such as "I'm upset about having to test my blood sugars." D) Anxiety related to new drug therapy, as evidenced by statements such as "I'm upset about having to test my bl ood sugars." Answer > D Formulation of nursing diagnoses is usually a three -step process. "Anxiety" is missing the "related to" and "as evidenced by" portions of defining characteristics. "Anxiety related to new drug therapy" is missing the "as evidenced by" portion of defining characteristics. The patient is to receive oral guaifenesin (Mucinex) twice a day. Today, the nurse was busy and gave the medication 2 hours after the scheduled dose was due. What type of problem does this represent? A) "Right tim e" B) "Right dose" C) "Right route" D) "Right medication" Answer > A "Right time" is correct because the medication was given more than 30 minutes after the scheduled dose was due. The nurse has been monitoring the patient's progress on a new drug regim en since the first dose and documenting the patient's therapeutic response to the medication. Which phase of the nursing process do these actions illustrate? a. Nursing diagnosis b. Planning c. Implementation d. Evaluation Answer > D Monitoring the pat ient's progress, including the patient's response to the medication, is part of the evaluation phase. Planning, implementation, and nursing diagnosis are not illustrated by this example. The nurse is assigned to a patient who is newly diagnosed with type 1 diabetes mellitus. Which statement best illustrates an outcome criterion for this patient? a. The patient will follow instructions. b. The patient will not experience complications. c. The patient will adhere to the new insulin treatment regimen. d. The patient will demonstrate correct blood glucose testing technique. Answer > D "Demonstrating correct blood glucose testing technique" is a specific and measurable outcome criterion. "Following instructions" and "not experiencing complications" are not specific criteria. "Adhering to new regimen" would be difficult to measure. Which activity best reflects the implementation phase of the nursing process for the patient who is newly diagnosed with hypertension? a. Providing education on keeping a journal of blood pressure readings b. Setting goals and outcome criteria with the patient's input c. Recording a drug history regarding over -the-counter medications used at home d. Formulating nursing diagnoses regard ing deficient knowledge related to the new treatment regimen Answer > A Education is an intervention that occurs during the implementation phase. Setting goals and outcomes reflects the planning phase. Recording a drug history reflects the assessment pha se. Formulating nursing diagnoses reflects analysis of data as part of planning. The medication order reads, "Give ondansetron (Zofran) 4 mg, 30 minutes before beginning chemotherapy to prevent nausea." The nurse notes that the route is missing from the o rder. What is the nurse's best action?
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