3111 HA: Chapter 2 Critical Thinking in Health Assessment

2. Considering the acronym OLD CART, the nurse is asking a newly admitted patient questions during the assessment process. The patient is a 35-year-old man who presents with pain in the upper arm since lifting weights 3 days ago. What question would be appropriate to ask that would give information for the "D" in the acronym. a. "has anything helped relieve the pain" b. "is there anything that makes the pain worse" c. "can you point to where the pain is located" d. "does the pain come and go or is it constant"

d. "does the pain come and go or is it constant" The "D" in OLD CART represents the duration of the symptom. Asking if the pain comes and goes provides an answer to that question.

3. A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data: a. reports of hair loss b. worried about appearance c. itching sensation all over body d. anxious appearance

d. anxious appearance Based on the data gathered from the client, the nurse can classify the anxious appearance is in inference the nurse is making; all of these are subjective abnormal findings

17. Subjective and objective data are both important parts of an assessment. Subjective data are things the patient or his or her family tells the nurse: True False

True

20. The nurse is developing goals after completing the assessment of a newly admitted medical patient. The nurse would document the goals under which part of the nursing process: a. planning b. diagnosis c. implementation d. evaluation

a. planning Goal setting and interventions are part of the planning section of the nursing process.

11. A client presents to the ED following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client: a. unable to feel his leg b. bleeding profusely from the wound c. presence of lethargy d. mild confusion

a. unable to feel his leg Based on the conditions in which the client has been brought to the healthcare facility, the client's inability to feel his legs can be noted as objective abnormal findings.

18. After collecting subjective data and objective data for the admission database, what is the nurse's next action: a. validate the client's identified problems b. set nurse-driven goals for the client c. evaluate effectiveness of nursing actions d. discuss the action plan with the client

a. validate the client's identified problems The nurse should develop a plan of care while adhering to the nursing process. After assessment, the client's problems should be validated. Mutual goal setting is recommended versus nurse-driven goal setting. Nursing actions should not be implemented before the plan of care is developed. The plan of care cannot be completed until the client's problems are validated and mutual goals are set.

6. The new RN tells her preceptor that she has always had trouble remembering all the steps of the nursing process. The preceptor tells the new grad student that an easy way is to think about the anagram: a. REEDA b. ADPIE c. PERRLA d. OLD CART

b. ADPIE The anagram ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation) can assist in remembering the steps of the nursing process.

9. The nurse recognizes the following to be a necessary component of performing an accurate assessment. (Select all that apply) a. inaccurate data b. documentation of data c. validation of data d. collection and organization of data e. incomplete data

b. documentation of data c. validation of data d. collection and organization of data Before you can begin to analyze data, you must make sure the assessment is accurately performed, which includes collection and organization, validation, and documentation of the data. You do not want to include any inaccurate or incomplete data--doing so will lead to a faulty assessment.

14. Which statement would demonstrate the correct method for writing an evaluation of patient progress after implementing the nursing process: a. patient needs to ambulate at least 1 more time during an 8-hour period b. patient ambulated 3/3 times during a planned 8-hour period c. patient was unable to complete ambulation goal during the shift d. patient ambulated once every 8 hours

b. patient ambulated 3/3 times during a planned Ambulating three of three planned times during an 8-hour shift is very specific and is the correct way to document an evaluation

5. The nurse observes no urine output in a client's indwelling urinary catheter drainage bag. What is the nurse's first action: a. perform a bladder scan b. apply suprapubic pressure c. verify positioning of the catheter d. collect a urinalysis

c. verify positioning of the catheter The nurse should follow the nurse process and complete the assessment of the catheter first, which includes checking position of the catheter. Applying suprapubic pressure, performing a bladder scan, and collecting a urine specimen are not the first actions before a complete assessment.

7. A hospital nurse is in the process of analyzing physical assessment data the nurse has collected on a patient. Which characteristics of critical thinking should the nurse employ in the analysis? Select all that apply. a. avoid considering the client's cultural background when analyzing data. b. reflect on thoughts before reaching a conclusion c. use past clinical experience to build knowledge d. use rationale to support opinions and decisions e. hypothesize one diagnosis before diagnosing the client

b. reflect on thoughts before reaching a conclusion c. use past clinical experience to build knowledge d. use rationale to support opinions and decisions When analyzing the data collected from the client during physical assessment, the nurse should develop the following characteristics of critical thinking--use rationale to support opinions and decisions, reflect on thoughts before reaching a conclusion, and use past experience to build knowledge. Hypothesizing only one diagnosis before diagnosing the clinet and avoiding considering the client's cultural background when analyzing data are two of the pitfalls the nurse should avoid at the analysis stage.

15. One characteristic of a nurse who is a critical thinker is the ability to: a. form an opinion quickly b. validate information and judgments c. offer advice to clients d. be right most of the time

b. validate information and judgments One characteristic of a critical thinker is the ability to validate information and judgements with experts in the field

8. The nurse recognizes that the second step or phrase of the nursing process is difficult. Why is data analysis a difficult step: a. final opinions or judgments must be made rapidly b. the nurse must be an expert in her field in order to interpret data accurately c. diagnostic reasoning skills are required to interpret data accurately d. opinions and comments are not relevant in making accurate interpretations of data

c. diagnostic reasoning skills are required to interpret data accurately As the second step or phase of the nursing process, data analysis is a very difficult step because the nurse is required to use diagnostic reasoning skills to interpret data accurately

19. The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to: a. get physicians orders to implement the plan b. set goals for the patient c. discuss the plan with the patient d. document the plan on the cardex for all to utilize

c. discuss the plan with the patient Sharing makes the assessment and plan with the patient will allow the patient to offer his or her opinion, concerns, and willingness to proceed with the interventions. This makes the patient an active participant in his or her plan of care.

13. The nurse gathers the following data: complaint of a headache and sore throat, redness noted on pharynx with white exudates on tonsils, minimal cough, temperature 100.6 & #x00B0; F orally. It was noted that the patient had another sore throat 2 weeks ago. The most appropriate nursing diagnosis for this data would be: a. ineffective health maintenance related to repeated sore throat b. stress related to illness c. impaired comfort related to headache and sore throat pain d. infection related to elevated temperature

c. impaired comfort related to headache and sore throat pain The priority diagnosis is related to the chief complaint of headache and sore throat.

1. A patient who is 2 says postoperative reports pain and requests pain medication. After assessing the patient's pain level, the nurse decides to give the patient oral Percocet instead of intravenous morphine. This nurse is doing which step of the nursing process? a. evaluation b. diagnosis c. implementation d assesment

c. implementation This step is implementation because the nurse is taking appropriate action by giving oral medication. Assessment is the first step of the nursing process when the nurse collects data. Diagnosis is determining the problem. Evaluation is the final step to see the patient has achieved established goals.

4. The nurse is grouping subjective and objective data. Which data would the nurse list as subjective: a. rales on auscultation b. IV site without redness c. 50% of meals eaten d. headaches began 3 days ago

d. headaches began 3 days ago Subjective data come from the patient or family. A headache that began 3 days ago is an example of information gained from the patient.

12. The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following: a. nursing intervention b. data organization c. nursing rationale d. nursing diagnosis

d. nursing diagnosis Data analysis is referred to as the diagnostic phase of the nursing process because the end result is the identification of a nursing diagnosis. A nursing intervention is done during the implementation phase, nursing rationale is identified when choosing the interventions, and data organization must be done during the collection of the data while still in the assessment phase

10. OLD CART is a mnemonic that will help the nurse remember the steps in the nursing process a. True b. False

false OLD CART is a mnemonic that can help the nurse ask specific questions when performing an assessment.

16. When clustering data, age can be a factor in determining the number of nursing diagnoses. The younger child typically has one diagnosis because he or she is more likely to have a single disease True False

true