Chapter 13: Blended Competencies, Clinical Reasoning and Processes of
A nurse is working with a group of staff members to address the needs of a client as they develop the client's interdisciplinary plan of care. Which question if asked by the nurse addresses the standard of breadth when judging the group's thinking? "Could you elaborate on that point a bit more?" "How could we find out whether that is true?" "Could you be more specific in your observations?" "Is there another way to look at this situation?"
"Is there another way to look at this situation?" Explanation: Breadth is demonstrated by asking whether there is another way to look at this situation. This question attempts to address other issues that may or may not be impacting the situation. Asking to elaborate demonstrates clarity; asking to find out if the issue is true reflects accuracy. The question about being more specific addresses precision.
Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)? A blood glucose level of 108 mg/dL A client report of shooting pain up the left leg Grip weakness in the right hand Crackles in bilateral lung bases
A client report of shooting pain up the left leg Explanation: Subjective data consists of information that the client can describe, also known as symptoms. Therefore, a client report of pain in the leg is an example of a subjective finding that the nurse would likely obtain when performing an ROS. A blood glucose level of 108 mg/dL, an observation of weakness in the right hand, and auscultation of crackles in bilateral lung bases are examples of objective data that the nurse or health care provider can observe and measure.
The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? Activity and rest Health promotion Nutrition Self-perception
Activity and rest Explanation: A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertinent for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.
The nurse is caring for an underweight female client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client? Administer a high-calorie diet, excluding wheat, rye, and oats. Administer a daily multivitamin. Monitor for allergies. Weigh client as needed.
Administer a high-calorie diet, excluding wheat, rye, and oats. Explanation: Because this client is underweight and has an allergy to wheat, rye, and oats, administering a high-calorie diet and no wheat, rye, and oats would be the most appropriate intervention to meet the specific needs of this client. Administering a multivitamin, monitoring for allergies, and weighing the client as needed are generalized nursing measures and not specific to this client.
The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the most appropriate nursing action? Assess the client's back visually. Document the rash in the client's chart. Establish a nursing diagnosis of Altered Skin Integrity. Report it to the health care provider.
Assess the client's back visually. Explanation: Assessment is the first phase in the nursing process, so the nurse should perform a visual assessment of the client's rash before proceeding to activities that pertain to later phases, such as reporting or documenting the rash or formulating a nursing diagnosis.
A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which action best demonstrates the nursing skill of caring in this situation? Assisting the client to sit up in a chair Assessing the abdominal incision Monitoring vital signs Notifying the health care provider of lab results
Assisting the client to sit up in a chair Explanation: Caring skills are nursing interventions that restore or maintain a person's health and may involve actions as simple as assisting with activities of daily living--the acts that people normally do every day, such as bathing, grooming, dressing, toileting, and eating. Assisting the client to sit up in the chair is an example of this type of caring behavior. The other options are important nursing tasks, but they are not demonstrating the art of caring.
While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking? Clarity Accuracy Precision Relevance
Clarity Explanation: The nurse's question reflects clarity, or the need for more information. Accuracy would be reflected in questions about the information being true. Precision is reflected by questions asking for more details or specifics. Relevance would be reflected by questions related to how something connects to the issue.
A nurse is conducting a client interview and gathers information from secondary sources. Which sources might the nurse use? Select all that apply. Client's children Client Client's caregiver Client's physician Client's previous admission record
Client's children Client's caregiver Client's physician Client's previous admission record Explanation: The client is the primary source of information for assessment. Secondary sources include family members, significant others, other health care professionals, health records, and literature review.
Recording prioritized outcomes in the plan of care ensures which benefit? Each nurse can select which priorities to accomplish. Continuity of care can be provided to the client. The client will reach the goals of the care plan. The nurse knows what the client wants.
Continuity of care can be provided to the client. Explanation: When outcomes are recorded and prioritized, each nurse can quickly determine priorities of care and the client benefits from continuity of care. The nurse may not pick and choose which priorities to accomplish, the plan does not ensure that the client will reach the goals, and the plan of care is more than the client's "wants."
Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill? Intellectual Technical Interpersonal Visual
Intellectual Explanation: Teaching requires knowledge about teaching-learning principles to convey. The intellectual skills used in implementation include problem solving, decision making, and teaching.
A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process? Diagnosis Planning Implementation Evaluation
Planning Explanation: During the planning phase, the nurse examines alternatives and judges the worth of evidence using this information to develop the plan of care for the client. During diagnosis, the nurse analyzes the assessment information to identify actual or potential responses to health problems. During implementation, the nurse carries out the plan of care. During evaluation, the nurse determines outcome attainment, revises plans, and identifies a client's perception of results.
A nurse who is not familiar with using automated intravenous (IV) pumps is moving to a unit that uses them frequently. The nurse is anxious about using the device. What is the most appropriate way for the nurse to lessen this anxiety? Just start using the device as needed when providing care to clients, maintaining a confident, positive attitude. Ask more experienced nurses on the unit to describe to the nurse how to use the device. Research the literature for best practices when using the device. Practice using the device under the supervision of a more experienced nurse before using it with a client.
Practice using the device under the supervision of a more experienced nurse before using it with a client. Explanation: Nurses are expected to possess certain technical skills to function in today's technologically advanced health care setting. The best way to learn and develop confidence in one's ability to perform such a technical skill is to practice it oneself under the supervision of someone who is already proficient in it. Just performing the skill on a client with any practice would be inappropriate, as the nurse could potentially injure or cause discomfort to the client. Simply having other nurses describe the procedure would not sufficiently prepare the nurse to perform it oneself. Although researching the literature for best practices related to using the device is a good idea, it would be as effective as practicing the skill oneself for building competence and confidence in one's ability to perform the skill.
Which are characteristics of one who has developed critical thinking skills? Creative, oriented to success, self-determined, and perfectionistic Curious, other-directed, fallible, and humble Resilient, authoritative, reactive, and private Self-aware, honest, persistent, and authentic
Self-aware, honest, persistent, and authentic Explanation: The characteristics of one who has developed critical thinking skills include: self-aware, genuine/authentic, effective communicator, curious/inquisitive, confident/resilient, honest, creative, proactive, persistent, and improvement-oriented.
Self-evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. This process is referred to as: promoting the nurse's self-esteem. reflective practice. assessment of oneself. learning from mistakes.
reflective practice. Explanation: Reflective practice is the use of self-evaluation by nurses committed to quality nursing practice. Learning from mistakes and assessment of oneself is part of the reflective practice, which improves the nurse's self-esteem in caring for clients.
The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as Supervisory Technical Surveillance Maintenance
Supervisory Explanation: The term "supervisory intervention" is applied in the context of overseeing a client's overall care.
A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask? "What happened?" "How did the client value the experience?" "Were assumptions made correctly?" "How did the client perceive the event?"
"What happened?" Explanation: Reflection at the most basic level begins with descriptions of events. The nurse would think about the situation, the people, and the environment and then recall what happened, including the sequence of events, both positive and negative feelings, the context of the situation, and the relationships involved. At higher levels of reflection, the nurse would ask what perceptions, judgments, and thoughts occurred; what values were placed on the experience; and what assumptions were made that may have been true or false.
At 0730, the nurse notes that the client states that pain is a 7 on a scale of 0 to 10. Based on this assessment, the nurse administers pain medication to the client. At 0800, the nurse evaluates the client and finds that pain is a 4 on a scale of 0 to 10. Which example of documentation most clearly communicates the initial morning assessment? 0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered. 0730: Client states that pain is severe. Pain medication administered. 0900: Client states pain from 0730 has decreased from a 7 to a 4 after medication was administered. 0800: Client states that pain has decreased.
0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered. Explanation: Documentation using the nursing process must be accurate, timely, and relevant. In the above example, documentation at 0730 for the initial assessment is timely, it is concise when assigning a number to the client's pain level, and it is relevant to the assessment at hand and the action that the nurse took based on the assessment: pain medication administration. Documenting the client's pain as severe or decreased is not concise; a pain scale should be used. Documenting at 0900 the evaluation of the assessment and intervention is not timely.
The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? Administer a prescribed medication to decrease the client's blood glucose level. Analyze the data and create an individualized nursing diagnosis. Follow up with the client later to determine whether the client's laboratory test results improve. Identify outcomes for the client with the client's input.
Analyze the data and create an individualized nursing diagnosis. Explanation: The second part of the nursing process is the analysis of data that can help determine nursing diagnoses. Because the nurse has the assessment findings of polydipsia, polyphagia, polyuria, and an increased HgbA1C level, the nurse can analyze these findings to help to determine the most appropriate nursing diagnosis. Once the nursing diagnosis is determined, then the nurse, with input from the client, can identify outcomes and interventions, such as medication administration, implement the interventions and evaluate them.
To implement the most effective care for clients in an acute care facility, which is the most appropriate action for a new nurse to take? Apply expert-level critical thinking skills Apply theoretical knowledge to present clinical situations Ask peers for advice prior to providing any clinical care to clients Maintain a detailed clinical log for evaluation
Apply theoretical knowledge to present clinical situations Explanation: To deal with the clients' problems appropriately, the nurse must apply theoretical knowledge to present clinical situations. Critical thinking skills are necessary, but these do not have to be at an expert level. Consulting with peers might be helpful, but the nurse should seek to apply knowledge to the clinical situation. A clinical log does not ensure effective care.
Which activity is the clearest example of the evaluation step in the nursing process? Checking the client's blood pressure 30 minutes after administering captopril Taking a client's blood pressure on both arms at the beginning of a shift Recognizing that the client's blood pressure of 172/101 is an abnormal finding Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading
Checking the client's blood pressure 30 minutes after administering captopril Explanation: Measuring the client's blood pressure after performing an intervention such as drug administration determines the extent to which the client has achieved the outcome desired, which in this case is lowered blood pressure. Initially checking the client's blood pressure is an example of assessment, whereas recognizing it as an anomaly constitutes diagnosis. Administering the drug is a form of implementation.
A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented? Clinical reasoning Caring Reflection Assessment
Clinical reasoning Explanation: Clinical reasoning is the process of making a nursing judgment that will provide safe and quality care. Caring is holistically meeting the needs of the client. Reflection is looking back on events that have occurred and learning from them how to improve one's practice. Assessment is careful observation and evaluation of a client's health status.
How can the nurse obtain a more complete database for a newly admitted client? Clustering of data Analysis of lab values Review of the chart Comprehensive client assessment
Comprehensive client assessment Explanation: By having a more complete database from several sources, including the client, the nurse can arrive at a more accurate conclusion. The nurse can obtain data from secondary sources, such as family members, significant others, other health care professionals, health records, and literature review. Clustering of data, analysis of laboratory values, and review of the chart are all done after gathering data through assessment to develop nursing diagnoses; they would not help the nurse gather more data on the client.
Which action exemplifies the purpose of evaluation in the nursing process? Decide whether to continue, modify, or terminate client care. Develop a prioritized list of nursing diagnoses. Develop an individualized plan of client care. Determine the client's health status, self-care ability, and need for nursing.
Decide whether to continue, modify, or terminate client care. Explanation: Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Outcome identification and planning specify the nursing diagnosis to the client's strengths, thereby individualizing the plan of care.
A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? Check the client's skin turgor. Formulate a plan of care based on risk for dehydration. Administer an additional liter of intravenous fluids. Determine whether the prescribed treatment was effective.
Determine whether the prescribed treatment was effective. Explanation: The sequence of the nursing process is assessment, diagnosis, planning, implementation, and evaluation. Checking skin turgor is an assessment. Formulating a care plan is part of planning. Administration of additional fluid occurs during implementation. The nurse evaluates whether the intervention was effective, as demonstrated by a rise in blood pressure and a decline in pulse rate.
The nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying? Developing technical skills Enjoying the rewards of mutual interchange Developing accountability Developing ethical/legal skills
Developing accountability Explanation: Nurses committed to interpersonal caring hold themselves accountable for the human well-being of clients entrusted to their care. Being accountable means being attentive and responsive to the health care needs of individual clients, being concerned for the client in all situations, and ensuring that continuity of care is in place when leaving a client. This is not an example of technical skills. Enjoying the rewards of mutual interchange means the nurse enriches everyday interactions by investing something of themselves in the relationship with the client and, in return, receiving something from the client. Developing ethical/legal skills refers to providing client care that provides advocacy for the client while mediating ethical conflicts and following legal guidelines.
Which action should the nurse associate with outcome identification and planning in the nursing process? Decides whether to continue, modify, or terminate nursing care Develops a prioritized list of nursing diagnoses Develops an individualized plan of nursing care Determines the client's health status, self-care ability, and need for nursing
Develops an individualized plan of nursing care Explanation: In the process of outcome identification and planning, the nurse adapts the nursing diagnosis to address the client's strengths, thereby individualizing the plan of care. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care.
A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is most likely in which phase of the nursing process? Assessment Diagnosis Planning Implementation
Diagnosis Explanation: The statement reflects a nursing diagnosis, which provides the basis for selecting interventions to achieve positive client outcomes. Assessment involves the collection of data. Planning involves preparing a client plan of care, which directs activities of the nursing staff in provision of client care. Implementation involves the actual initiation of the plan, evaluation of the response to the plan, and recording of nursing actions and client response to the actions.
A nurse should have critical thinking attitudes to develop critical thinking skills. One attitude the nurse should possess is orderly thinking to do what is best. Which term best suits this attitude description? Discipline Perseverance Integrity Humility
Discipline Explanation: Following orderly thinking to do what is best is called discipline. Perseverance is staying determined to keep trying until the goal is achieved. Integrity is being honest and willing to adhere to principles in the face of adversity. Humility is admitting one's own limitations.
A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment? Document that the client is talking back to the voices in the client's head. Document this assessment based on the client's behaviors. Do not document this assessment because the client could be using a wireless device to talk to family. Do not document this assessment because it is subjective.
Document this assessment based on the client's behaviors. Explanation: Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs. Assessment should be documented accurately, completely, concisely, factually, and in a timely manner. To document factually, the nurse should document the client's behaviors, not the nurse's interpretation of the behaviors. In this situation, the nurse could and should quickly determine whether the client is using a wireless device to communicate with family and then document the client's behavior only if needed. The nurse's observation of the client talking out loud when no one else is in the room is an objective, not subjective, finding (the client reporting hearing voices in the head is an example of a subjective finding, as it is not observable by the nurse). In any case, both objective and subjective findings should be documented.
A hospital client has an aggressive fungal infection in the right eye that necessitates evisceration (removal of the eye). Consequently, the client requires twice-daily packing and dressing changes to the orbit. Which of the nurse's actions in the care of this client most clearly demonstrates interpersonal skills? Ensuring the client's privacy during dressing changes and providing an explanation during the procedure Documenting the condition of the client's orbit and the procedure of the dressing change in an accurate and timely manner Understanding the anatomy and physiology of the affected parts of the client's body Maintaining aseptic technique when performing the dressing change
Ensuring the client's privacy during dressing changes and providing an explanation during the procedure Explanation: A central aspect of a nurse's interpersonal skills is maintaining privacy and dignity, as well as keeping clients informed during their care. Documentation is an outcome of legal/ethical skills, whereas knowledge of anatomy and physiology demonstrates cognitive skill. The maintenance of asepsis involves technical skill.
Place the nursing activities in the order that they would most likely occur when a health care professional uses the nursing process. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Establishing the database 2Interpreting and analyzing client data 3Establishing priorities 4Carrying out the plan of care 5Measuring how well the client has achieved desired outcomes 6Modifying the plan of care (if indicated)
Establishing the database Interpreting and analyzing client data Establishing priorities Carrying out the plan of care Measuring how well the client has achieved desired outcomes Modifying the plan of care (if indicated) Explanation: A complete database must first be established in order to allow for interpretation and analysis of the client data. Once problems or potential client problems have been identified prioritization can occur in the form of establishment of goals/outcomes and planned nursing interventions. The plan can then be carried out, which leads to measuring if the client achieved the desired outcomes. If outcomes were not met or partially met the plan of care can be modified.
The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0 to 10. There is an order for intravenous pain medication every 4 hours as needed. The nurse administers the prescribed pain medication to the client. What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0 to 10? Call the surgeon to report the pain level. Continue making rounds on other clients and let the client rest. Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect. Modify the plan of care to include an additional pain medication because the client's pain is so severe.
Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect. Explanation: In the evaluation phase of the nursing process, the nurse measures the extent to which the client has achieved outcomes. This phase helps determine whether the nurse should terminate, continue, or modify the plan of care. To ensure that this client's plan of care is appropriate, the nurse must evaluate the client's response to the intervention of administering pain medication. The nurse must evaluate the results of the intervention that has already been implemented before determining the need to modify the plan of care. Therefore, neither calling the surgeon nor modifying the plan of care is appropriate at this time, and continuing to make rounds on other clients would not address this client's needs specifically.
The nurse assesses a client's blood pressure, which is 160/90 mm Hg. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure, finding it to be 140/78 mm Hg. Which action has the nurse implemented? Evaluating Appraising Planning Implementing
Evaluating Explanation: The nurse is collecting data to evaluate the effectiveness of a medication that was administered. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care, performing interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments. Appraising is not a discrete part of the nursing process.
The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should the nurse determine this phase will include? Select all that apply Evaluation does not involve client assessment. Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. Only factors that positively affect the outcome should be identified during evaluation. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.
Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care. Explanation: The evaluation phase, which is the last phase of the nursing process, measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. Evaluation does involve nursing assessment to determine whether the client has met the outcome. The nurse should identify both factors that positively and negatively affect the outcome to assist with meeting the client's outcomes, and evaluation findings should be documented daily in the client's record.
Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing? Evidence-based practice Informatics Person-centered care Teamwork and collaboration
Evidence-based practice Explanation: Evidence-based practice as defined by Quality and Safety Education for Nurses (QSEN) indicates the need to value evidence-based practice findings to ensure that the best clinical practice is provided for clients. When health care institutions change their policies based on research, this reflects the significance of this QSEN competency. Informatics is the use of technology to gather and use data to improve client health. Person-centered care is a model of patient care based on holistic roots in which the nurse or other caregiver uses every clinical encounter to assess how the person is doing and to communicate respect, compassion, and care. Teamwork and collaboration are values in nursing that emphasize the benefits of health care team members working together to meet clients' needs rather than just individually.
Which statement regarding critical thinking in nursing is true? It is a systematic way of thinking. It shows trends and patterns in client status. It makes judgments based on conjecture. It supplies validation for reimbursement.
It is a systematic way of thinking. Explanation: Critical thinking is a systematic way of thinking that involves purposeful, outcome-directed thinking. Critical thinking makes judgments based on evidence rather than conjecture. Providing a foundation for evaluation and quality improvement, showing trends and patterns in client status, and supplying validation for reimbursement are functions served by documentation.
The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next? Develop an additional nursing diagnosis to meet the client's health needs. Change the nursing diagnosis because the client's problem was falsely identified. Modify the plan of care and interventions to meet the client's needs. Reassess the client for more symptoms of deficient fluid volume.
Modify the plan of care and interventions to meet the client's needs. Explanation: The nurse should review the plan of care and its implementation periodically and, as needed based on evaluation, modify them to meet the client's needs. Because this client continues to exhibit symptoms identified by the nursing diagnosis, the implementation should be modified to better meet the client's needs and outcomes. Because the original nursing diagnosis appears to be accurate, there is no indication that it falsely identifies the client's problem or that another one is needed. There is no need to reassess the client for more symptoms of deficient fluid volume because it is evident that the client has this problem.
An adolescent with diabetes has a nursing diagnosis of noncompliance related to activities that interfere with the treatment plan as evidenced by elevated blood glucose levels. The outcome for this client is to maintain blood glucose levels between 70 and 110 mg/dL (3.89 and 6.11 mmol/L). The main intervention is to educate the client about the effects of abnormal blood glucose level on the body and ensure that the client has the resources to be compliant. Evaluation reveals that the client's blood glucose level remains elevated and that the outcome has not been met. What is the most appropriate action by the nurse? Modify the plan of care to find alternative ways to meet client needs. Reevaluate the plan of care at a later date. Refer the client to the social worker. Terminate the plan of care because the client will not listen to health care providers.
Modify the plan of care to find alternative ways to meet client needs. Explanation: The evaluation phase of the nursing process measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. On evaluation, this client had not met the outcome. Therefore, the most appropriate response by the nurse is to modify the plan of care to find alternative ways of meeting this client's needs. Reevaluating the plan of care at a later date does not address this client's needs in a timely fashion, nor does referring to the social worker. Terminating the plan of care is not appropriate if the client has not found a way to address the problems identified in the nursing diagnosis.
Which statements are true about informatics in nursing practice? Select all that apply. Computers do not help with communication, but deter it because of the lack of personal interaction. Informatics only involves documentation of timely and accurate charting. Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision making.
Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision making. Explanation: Traditionally, documentation consisted of timely and accurate charting. However, the QSEN updated definition is expanded and calls for using information and technology to communicate, manage knowledge, mitigate error, and support decision making. Nurses should value technologies that support error prevention and care coordination.
A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care? Nursing process Clinical reasoning Reflection Experience
Nursing process Explanation: Although clinical reasoning, reflection, and experience are important components of nursing, the nursing process is recognized as the method of practicing nursing. It is the model on which professional nursing standards are based. Although it sometimes is criticized for not being adaptable to the changing health care environment, the nursing process remains the almost universally accepted method for providing nursing care.
A nurse is engaged in diagnostic reasoning to propose appropriate nursing diagnoses for a client. Place the steps in the order that they would occur from first to last during this process. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Organizing the existence of cues 2Generating possible diagnoses 3Comparing cues to possible diagnoses 4Conducting a focused data collection 5Validating diagnoses
Organizing the existence of cues Generating possible diagnoses Comparing cues to possible diagnoses Conducting a focused data collection Validating diagnoses Explanation: Diagnostic reasoning is the process of gathering and clustering data to draw inferences and propose diagnoses. NANDA-I (Herdman, 2012) has formulated five steps of diagnostic reasoning: organizing the existence of cues, generating possible diagnoses, comparing cues to possible diagnoses, conducting a focused data collection, and validating diagnoses.
Which is the most appropriate example of the assessment phase of the nursing process? Documenting the administration of a medication provided for pain Evaluating the temperature of a client given medication for a fever Including a nursing diagnosis of Acute Pain in the client's plan of care Palpating a mass in the right lower quadrant of the abdomen
Palpating a mass in the right lower quadrant of the abdomen Explanation: Palpation of a mass in the abdominal cavity is an example of assessment in the nursing process through collecting data that determine the need for nursing care. Documentation of medication administration is an intervention. Evaluating the temperature of a client given medication for a fever is a better example of evaluation through assessment. Including a nursing diagnosis in the plan of care is part of determining actual and potential health problems.
A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client? Add a new nursing diagnosis in the nurse's own words to individualize the plan of care. Keep resolved nursing diagnoses as part of the plan of care in case the related problems return. Do not allow the client to review the client's own nursing diagnoses. Prioritize the nursing diagnoses.
Prioritize the nursing diagnoses. Explanation: After performing a nursing assessment, data should be analyzed and compiled into actual and potential health problems and documented as nursing diagnoses. It is the nurse's responsibility to prioritize the nursing diagnoses, thereby prioritizing the care of the client. Resolved nursing diagnoses should be deleted from the plan of care as soon as they are resolved and replaced with new ones when appropriate. Nursing diagnoses should be written in a nonjudgmental way and in legally advisable terms, not in the nurse's own words. The plan of care is individualized for each client, and therefore the client should be aware of what is included.
What is the most beneficial use of the nursing process in addressing the needs of the client? Provides a universally applicable framework for nursing activities Allows the nurse to determine a medical diagnosis for the client Allows student nurses to work on assignments Targets desired outcomes for particular illnesses, procedures, or conditions
Provides a universally applicable framework for nursing activities Explanation: The nursing process can be used with all clients, sick or well, of all ages and in all settings. The nursing process was not designed for use by students in their assignments. Critical pathways, not the nursing process, target desired outcomes for particular illnesses, procedures, or conditions. Medical diagnoses are determined by physicians.
Which is the best example of person-centered care provided by a registered nurse? Administration of pain medication every 4 hours to a client who is postoperative Development of a plan of care for a new admission Insertion of a nasogastric tube for gastric decompression Reassuring a client who is anxious about a procedure
Reassuring a client who is anxious about a procedure Explanation: Person-centered care involves consideration of a client holistically by incorporating an awareness of the client's feelings into the provision of care. Person-centered care is different from task-oriented care in that the task-oriented nurse is only focused on completing tasks in a timely manner. Reassuring a client who is anxious about a procedure shows caring in that the nurse considers the client's feelings about the procedure and does not focus only on the procedure as a task in and of itself. Administering pain medicine, development of the plan of care, and insertion of a nasogastric tube are all important tasks but are not the best example of person-centered care.
The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action? During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. After turning the client alone, the nurse realizes that the nurse should have insisted on having help. The nurse decides to turn the client every 4 hours because everyone is too busy to help.
Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. Explanation: There are three types of reflection as defined by Schon: reflection-in-action, reflection-on-action, and reflection-for-action. Reflection-for-action is the desired outcome of the first two types and helps the person to think about how future actions might change as a result of the reflection. When the nurse realizes the need for help turning the client when first attempting to turn the client, this is reflection-in-action. When reflecting whether everyone is using appropriate resources, this is reflection-on-action. When adapting the client's plan of care based on these other reflections, this is reflection-for-action. Turning an obese client without assistance is unsafe and resources should be used. The client's outcomes should not be jeopardized by altering the plan of care due to the time constraints of staffing.
Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes? Memorization Reflection Assessment Evaluation
Reflection Explanation: Reflection is defined as a purposeful activity that leads to action, improvement of practice, and better client outcomes. Memorization is strict learning of material for recall. Assessment is careful observation and evaluation of a client's health status. Evaluation is the assessment and review of the quality and suitability of the care given and the client's responses to that care.
The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain? Repositioning the client Administering extra pain medication Documenting opioid dependence Administering a placebo
Repositioning the client Explanation: The nursing process focuses on the client's unique problems, setting priorities, developing goals and outcome criteria, and selecting nursing interventions. Repositioning the client is a nursing intervention; it is nonpharmacologic and does not require a prescription from the health care provider and can assist with pain relief. Administering extra pain medication may only be done with a prescription from the health care provider. Documenting opioid dependence is inappropriate and not within the nurse's scope of practice. Administering a placebo is inappropriate and unethical.
Which statement is true of the nursing process? Scientific problem solving can occur within the nursing process. It is a valid alternative to using intuition to respond to nursing situations. It is more appropriate in medical surgical settings than community health care. Trial-and-error problem solving is an efficient use of the nurse's time.
Scientific problem solving can occur within the nursing process. Explanation: Problem solving and the nursing process are not competing or mutually exclusive processes. Rather, scientific problem solving is the focus of the nursing process. One of the strengths of the nursing process is that it is applicable to all nursing areas, from medical-surgical to community health settings.
The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship? Show respect for the client, and engage in open communication in getting to know the client. Approach the client as part of the job, and complete nursing care quickly to promote comfort. Recognize how the approach affects client care, and describe why you have to do things your way. Introduce yourself, and then accomplish nursing care activities efficiently to allow the client to rest.
Show respect for the client, and engage in open communication in getting to know the client. Explanation: Respect for the client's dignity, and establishing a caring relationship, is furthered by mutual exchange of communication. Approaching care/client as a job, doing things without client input, and doing things your way and efficiently are not necessarily therapeutic, nor do they initiate communication.
Which outcome should the nurse recognize as being the most appropriate for a client with a nursing diagnosis of risk for infection? The client takes the prescribed antibiotic. The client has a normal temperature and no signs or symptoms of infection. The client understands what symptoms to monitor for. The client takes the client's own temperature daily.
The client has a normal temperature and no signs or symptoms of infection. Explanation: The evaluation phase of the nursing process measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. Evaluation related to the temperature and absence of signs of infection directly addresses the client outcome and individualizes the plan of care. Taking an antibiotic, understanding symptoms to monitor for, and/or taking the client's temperature daily do not specifically address the client outcome.
The nurse is preparing to document the nursing diagnoses for a client. What is the most appropriate outcome for the nursing diagnosis of impaired gas exchange? The client will have clear breath sounds. The client will have decreased work of breathing. The client will maintain a pulse oximeter reading of greater than 94% (0.94 L). The client will maintain a respiratory rate between 12 and 20 breaths per minute.
The client will maintain a pulse oximeter reading of greater than 94% (0.94 L). Explanation: Outcomes can be short- or long-term, and short-term outcomes should describe a single, observable, and measurable behavior. Outcomes are created to specify a resolution to the identified health problem reflected in the nursing diagnosis. Maintaining a pulse oximeter reading greater than 94% (0.94 L) specifies a resolution to gas exchange problems that occur in the lower airways. Having clear breath sounds, decreased work of breathing, and a normal respiratory rate only assures that the airway is established but not that gas exchange is taking place to its fullest extent.
A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to: complete the postoperative assessment. evaluate the abdominal dressing for drainage. administer pain medication. expect the client to be drowsy, and let the client rest.
complete the postoperative assessment. Explanation: Assessment is the first priority, which would include breathing, level of consciousness, vital signs, dressings, intravenous sites, and pain level. After assessing, pain medication may be needed. The nurse may expect the client to be drowsy, but ongoing assessment is required nonetheless.
An obese client is in the clinic to start on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client? The client will: create an exercise plan that is realistic and valued. exercise every day for at least 30 minutes. only eat three meals per day. stop eating meat and walk every day after dinner.
create an exercise plan that is realistic and valued. Explanation: Outcomes should be realistic and valued by the client and family. If this client creates an exercise plan that the client values and is realistic, then the client will be more likely to meet the outcome. Exercising every day, only eating three meals per day, or excluding meat from the diet may not be realistic or valued by the client who openly acknowledges liking to eat and does not like to exercise.
The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse? involving the client with all the steps of the process in care development ensuring the client is informed after decisions are made with care delivery requiring the client to evaluate the plan of care after implementation implementing the standard plan of care for all clients with diabetes mellitus
involving the client with all the steps of the process in care development Explanation: Because the plan of care should be client-centered, the client should be directly involved with all phases of the creation of the care plan. This will involve assessing the learning needs of the client as well as goal setting, implementation, and evaluation. The client should be involved and not just informed of decisions regarding care during the evaluation phase. The client may be involved with the evaluation but the nurse will assess to determine if the plan of care is effective and if the client's goals are being met. Standard plans of care do not address the needs of the individual and should be tailored to the individual client.
A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as: life-sized mannequins with a sophisticated computer interface. small, doll-like devices used for measuring vital signs. health care equipment that has practice modes. life-saving equipment that resuscitates clients in cardiac arrest.
life-sized mannequins with a sophisticated computer interface. Explanation: The human client simulator, a life-sized mannequin with a sophisticated computer interface, presents students with clinical scenarios that evolve based on decisions that students make. The other equipment and devices described are tools used to learn and practice skills, rather than build on critical thinking skills.
A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is newly diagnosed, the nurse included in the plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in the client? The client will: log all meals in a diary for the next 6 weeks. maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). maintain a normal HgbA1C. not exhibit signs and symptoms of hypoglycemia/hyperglycemia.
maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). Explanation: Outcomes can be short- or long-term, and short-term outcomes should describe a single, observable, and measurable behavior. Maintaining a blood sugar between 70 and 110 mg/dL (3.89 and 6.11 mmol/L) is short-term and is a single, observable, measurable outcome. Logging meals for 6 weeks and maintaining a normal HgbA1C are more long-term goals. Not exhibiting signs and symptoms of hypoglycemia/hyperglycemia is not as measurable/observable as monitoring the blood sugar.
A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified: outcome. objective data. nursing diagnosis. intervention.
outcome. Explanation: This statement is an outcome statement that focuses on the client, is realistic, and is measurable. The pain report is objective data; subjective data would include information from the client, such as reports of pain or anxiety. Nursing diagnosis is a clinical judgment about an individual, family, or community experience/response to an actual or potential health problem. Intervention would be the action to be completed based on the nursing diagnosis and intended outcome (e.g., administering a prescribed analgesic).
