ch. 6 Flashcards
Which nursing diagnosis is appropriate for the patient who has just received a prescription for a
new medication?
a. Noncompliance related to new drug therapy
b. Impaired memory related to new drug therapy
c. Lack of knowledge regarding newly prescribed drug therapy
d. Deficient knowledge related to newly prescribed drug therapy
ANS: D
A patient who has a limited understanding of newly prescribed drug therapy may have the
nursing diagnosis of deficient knowledge. Noncompliance is incorrect because that term implies
that the patient does not follow a recommended regimen, which is not the case with a newly
prescribed drug. Impaired memory is not appropriate in this situation. “Lack of knowledge” is
not a nursing diagnosis.
The nurse is developing a care plan for a patient who will be self-administering insulin
injections. Which statement reflects a measurable outcome?
a. The patient will know about self-administration of insulin injections.
b. The patient will understand the principles of self-administration of insulin
injections.
c. The patient will demonstrate the proper technique of self-administering insulin
injections.
d. The patient will comprehend the proper technique of self-administering insulin
injections.
ANS: C
The word demonstrate is a measurable verb, and measurable terms should be used when
developing goals and outcome criteria statements. The other options are incorrect because the
terms know, understand, and comprehend are not measurable terms.
During a nursing assessment, which question by the nurse allows for greater clarification and
additional discussion with the patient?
a. “Are you allergic to penicillin?”
b. “What medications do you take?”
c. “Have you had a reaction to this drug?”
d. “Are you taking this medication with meals?”
ANS: B
Asking “What medications do you take?” is an open-ended question that will encourage greater
clarification and additional discussion with the patient. The other options are examples of closedended questions, which prompt only a “yes” or “no” answer and provide limited information.
The nurse is setting up a teaching session with an 85-year-old patient who will be going home on
anticoagulant therapy. Which educational strategy would reflect consideration of the age-related
changes that may exist with this patient?
a. Show a video about anticoagulation therapy.
b. Present all the information in one session just before discharge.
c. Give the patient pamphlets about the medications to read at home.
d. Develop large-print handouts that reflect the verbal information presented.
ANS: D
Developing large-print handouts addresses altered perception in two ways. First, by using visual
aids to reinforce verbal instructions, one addresses the possibility of decreased ability to hear
high-frequency sounds. By developing the handouts in large print, one addresses the possibility
of decreased visual acuity. Showing a video does not allow discussion of the information;
furthermore, the text and print may be small and difficult to read and understand. Presenting all
the information in one session before discharge also does not allow for discussion, and the
patient may not be able to hear or see the information sufficiently. Because of the possibility of
decreased short-term memory and slowed cognitive function, giving pamphlets to read may not
be appropriate.
When the nurse teaches a skill such as self-injection of insulin to the patient, what is the best
way to set up the teaching/learning session?
a. Provide written pamphlets for instruction.
b. Show a video, and allow the patient to practice as needed on his own.
c. Verbally explain the procedure, and provide written handouts for reinforcement.
d. After demonstrating the procedure, allow the patient to do several return
demonstrations.
ANS: D
Return demonstration allows the nurse to evaluate the patient’s newly learned skills. The
techniques in the other options are incorrect because those suggestions do not allow for
evaluation of the patient’s technique.
- A patient with a new prescription for a diuretic has just reviewed with the nurse how to include
more potassium in her diet. This reflects learning in which domain?
a. Cognitive
b. Affective
c. Physical
d. Psychomotor
ANS: A
The cognitive domain refers to problem-solving abilities and may involve recall and knowledge
of facts. The affective domain refers to values and beliefs. The term physical does not refer to
one of the learning domains. The psychomotor domain involves behaviors such as learning how
to perform a procedure.
During an admission assessment, the nurse discovers that the patient does not speak English.
Which is considered the ideal resource for translation?
a. A family member of the patient
b. A close family friend of the patient
c. A translator who does not know the patient
d. Prewritten note cards with both English and the patient’s language
ANS: C
The nurse should communicate with the patient in the patient’s native language if at all possible.
If the nurse is not able to speak the patient’s native language, a translator should be made
available so as to prevent communication problems, minimize errors, and help boost the patient’s
level of trust and understanding of the nurse. In practice, this translator may be another nurse or
health care professional, a nonprofessional member of the health care team, or a layperson,
family member, adult friend, or religious leader or associate. However, it is best to avoid family
members as translators, if possible, because of issues with bias, misinterpretation, and potential
confidentiality issues.
The nurse is teaching a 16-year-old patient who has a new diagnosis of type 1 diabetes about
blood glucose monitoring and the importance of regulating glucose intake. When developing a
teaching plan for this teenager, which of Erikson’s stages of development should the nurse
consider?
a. Trust versus mistrust
b. Intimacy versus isolation
c. Industry versus inferiority
d. Identity versus role confusion
ANS: D
According to Erikson, the adolescent (12 to 18 years of age) is in the identity versus role
confusion stage of development. Trust versus mistrust reflects the infancy stage; intimacy versus
isolation reflects the young adulthood stage; and industry versus inferiority reflects the schoolage stage of development.
A 60-year-old patient is on several new medications and expresses worry that she will forget to
take her pills. Which action by the nurse would be most helpful in this situation?
a. Teaching effective coping strategies
b. Asking the patient’s prescriber to reduce the number of drugs prescribed
c. Assuring the patient that she will not forget once she is accustomed to the routine
d. Assisting the patient with obtaining and learning to use a calendar or pill container
ANS: D
Calendars, pill containers, or diaries may be helpful to patients who may forget to take
prescribed drugs as scheduled. The nurse must ensure that the patient knows how to use these
reminder tools. Teaching coping strategies is a helpful suggestion but will not help with
remembering to take medications. Asking the prescriber to reduce the number of drugs that are
prescribed is not an appropriate action by the nurse. Assuring the patient that she will not forget
is false reassurance by the nurse and inappropriate when education is needed.
Which are appropriate considerations when the nurse is assessing the learning needs of a patient? (Select all that apply.) a. Cultural background b. Family history c. Level of education d. Readiness to learn e. Health beliefs
ANS: A, C, D, E
Family history is not a part of what the nurse considers when assessing learning needs. The other
options are appropriate to consider when the nurse is assessing learning needs.
