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 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 blood sugars.‖ ANS: 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 statement beginning ―Anxiety related to anxious feelings‖ is incorrect because the ―related to‖ section is simply a restatement of the problem ―anxiety,‖ not a separate factor related to the response. DIF: COGNITIVE LEVEL: Understanding (Comprehension) TOP: NURSING PROCESS: Nursing Diagnosis MSC: NCLEX: Safe and Effective Care Environment: Management of Care 2. 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 time‖ b. ―Right dose‖ c. ―Right route‖ d. ―Right medication‖ ANS: A ―Right time‖ is correct because the medication was given more than 30 minutes after the scheduled dose was due. ―Dose‖ is incorrect because the dose is not related to the time the medication administration is scheduled. ―Route‖ is incorrect because the route is not affected. ―Medication‖ is incorrect because the medication ordered will not change. DIF: COGNITIVE LEVEL: Applying (Application) TOP: NURSING PROCESS: Implementation MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control 3. The nurse has been monitoring the patient‘s progress on a new drug regimen since the first dose and documenting the patient‘s therapeutic response to the medication. Which phase of the nursing process do these actions illustrate?
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