Fundamentals Ch 10

A nurse educator correctly states that which behaviors are characteristic of nurses who are critical thinkers? Select all that apply.

Alert to context so that the need for modification can be identified and changes to the plan of care can be made Responsible and accountable for own actions

Nurses who prize their role in securing client well-being are sensitive to the ethical and legal implications of nursing practice. Which are examples of these ethical/legal skills? Select all that apply.

Being trusted to act in ways that advance the interests of clients Being accountable for practice to oneself, the client, the caregiving team, and society Acting as an effective patient advocate

The clinical nurse manager understands that which types of knowledge are required for competent clinical reasoning in nursing? Select all that apply.

Demonstrates basic mathematical problem solving Organizes and manages time efficiently Understands nursing and medical terminology

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?

Determine whether the prescribed treatment was effective.

The nurse is working with the parents of a young child who has been diagnosed with type 1 diabetes. Which of the following learning activities best exemplifies a constructivist approach to educative practice?

Dialoguing with the parents about what they would do if the child were invited to a party where there will be cake and candy

A nursing student is reading a research article that challenges many of the established practices around providing health education to patients and families. When reading this article, the nurse should do which of the following?

Engage critically with the text while reading it.

Place the nursing activities in the order that they would most likely occur when a health care professional uses the nursing process.

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)

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply

Impaired mobility Imbalanced nutrition Ineffective coping

Which statement best conveys the role of intuition in nurses' problem solving?

Intuition can be a clinically useful adjunct to logical problem solving.

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

Which is the most appropriate example of the assessment phase of the nursing process?

Palpating a mass in the right lower quadrant of the abdomen

The nurse has measured from the tip of the client's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing

The registered nurse (RN) is receiving shift report from another RN about a client admitted for dehydration. In report, the client has been prescribed IV fluids and an antibiotic. The oncoming RN asks why the antibiotic has been prescribed. This is an example of which consideration involved in the process of critical thinking?

Purpose of thinking

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

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.

Which outcome does the nurse recognize as being the most appropriate for the client with a nursing diagnosis of risk for infection?

The client has a normal temperature and no signs and symptoms of infection. ^cuz thats the outcome you want

A nursing student is explaining the educative role of nurses to a group of peers who are in other fields. What historical factor should the student describe when explaining this nursing role?

The emergence of nursing as a professional occupation

A nurse has chosen to implement the principles of andragogy into her personal vision of educative nursing practice. What practice will guide the nurse's teaching and learning activities?

The nurse will focus on information that is directly relevant to the patient's needs. One of the major principles of andragogy is the emphasis on the practical RELEVANCE of information. Andragogy does not always presume that the patient already knows everything that he or she needs to know and it is not characterized by a process of "test-teach-test." Andragogy does not deny the value of visual means of communication.

A nurse prompted a student nurse to the fact that a patient's condition was about to deteriorate despite no objective change in the patient's status. The nurse explains to the student that she had "gut feeling" that the patient was about to deteriorate. How should the student best interpret the nurse's decision-making?

The nurse's intuition is a recognized component of critical thinking in nursing

Nurses use the nursing process to solve problems in their practices. Which statements describe the common use of problem solving in the nursing process? Select all that apply.

The scientific problem-solving method is closely related to the more general problem-solving process (the nursing process) commonly used by health care professionals as they work with clients. 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:Today, nurses acknowledge the positive role of intuitive thinking in clinical decision making. Critical thinking in nursing can be intuitive or logical or a combination of both.

Which statements are true about the implementation phase of the nursing process? Select all that apply.

This phase promotes wellness and restores health. Care provided during implementation should be documented in the client's chart. Implementation is the process of carrying out the plan of care.

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:

complete postoperative assessment.

The purpose of the assessment phase of the nursing process is to:

develop a prioritized list of nursing diagnoses.

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 NOT subjective data

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:

uses critical thinking to direct care for the individual client.

The nurse is developing a plan of care for a client with a fractured femur, is in traction, and will be restricted to bed for some time. Which domain should the nurse look to for developing a nursing diagnosis based on this client's musculoskeletal health problems?

Activity/Rest This question is specifically related to this client's inability to move and musculoskeletal issues; therefore, the domain that would provide the most options for nursing diagnosis would be that of activity and rest.

The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats. What is the most appropriate intervention for this client with a nursing diagnosis of imbalanced nutrition: less than body requirements?

Administer 2500 calorie (10,500 kJ) diet, excluding wheat, rye, and oats

The nurse is caring for a client that presents with polydipsia, polyphagia, and polyuria. The clients labs reveal in increased Hb A1C, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?

Analyze data and create an individualized nursing diagnosis.

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process?

Assessment

The nurse is teaching about the nursing processes. In which order should the nurse explain the phases to the student nurse?

Assessment Diagnosis Planning Implementation Evaluation

A nursing student provided care for a patient who had a paradoxical reaction to an antianxiety medication. What activity will best promote the student's critical thinking around this incident?

Becoming curious about why the patient had this unexpected reaction

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

A nurse has referred some of her colleagues to a website that calls into question the infection control practices on the unit. Based on the information on the website, the nurse recommends loosening the enforcement of isolation precautions. Before implementing these recommendations, the nurses should do what?

Critically evaluate the source of this new information.

A nurse administers medications to a client. What step of the nursing process would the nurse perform next?

Evaluating

Which stage of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?

Evaluation

Which statements are true regarding the evaluation phase of the nursing process? Select all that apply.

Evaluations should be documented daily in the client record. Evaluation is the last part of the nursing process. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.

A nurse is demonstrating critical thinking when applying the nursing process to client care. Place the behaviors in the order in which they would occur from first to last based on the nursing process.

Explore ideas Interpret evidence Detect bias Predict consequences Identify client's perception of results

Controversy exists on a nursing unit regarding the most appropriate protocol for changing patients' peripheral intravenous sites. What activity should the nurse prioritize when applying the principles of evidence-based practice to this controversy?

Identifying valid and reliable research studies that address the issue

A nurse is engaged in the assessment phase of the nursing process. When completing the physical exam, which techniques would the nurse likely use? Select all that apply.

Inspecting Auscultating Percussing Palpating *Think physically assessing NOT interviewing, interviewing is part of the history where the nurse gathers data about the client's functional health, including perception and interpretation of problems.

A client is admitted to the hospital with an abscess on the leg that will not heal after multiple treatment options as an outpatient. The nurse knows from past experiences that the appearance of this type of wound in clients heavily suggests a resistant bacterial infection and the need for contact isolation and IV antibiotics. The nurse begins to prepare for this admission. What type of problem solving does this exhibit?

Intuitive problem-solving occurs when an experienced person makes decisions or solves problems based on experiences that he or she has had that share similarities or associations. Experiential is not a defined type of problem solving.

Which is a characteristic of person-centered care?

It is a framework for providing care.

A nurse has been asked to present an orientation program to a group of newly graduated nurses. As part of the program, the nurse plans to reemphasize the need for critical thinking. When describing this concept, which characteristics would the nurse likely include? Select all that apply.

It requires a systematic and logical approach It requires a conscious and deliberate effort. It involves judgments based on evidence.

A nurse has developed a plan of care for an adult client. What nursing function is important when using a nursing diagnosis to guide the care of this client?

Prioritize the nursing diagnoses. After performing a nursing assessment, data should be analyzed and compiled into actual and potential health problems and documented as nursing diagnosis. It is the nurse's responsibility to prioritize the nursing diagnosis, thereby prioritizing the care of the client.

A nursing student confides in a colleague, "I'm scared that the nurses of the unit will find out just how little I know about nursing." The student's colleague recognizes that the student is experiencing the Impostor Syndrome. How can the colleague best support this student?

Reassure the student that this is a common and normal belief that has no factual basis.

What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations?

Reflection

The nurse is caring for a pediatric client with respiratory distress. Upon assessment the client has increased respirations and work of breathing (WOB). Breath sounds are adventitious and the client has thick yellow/green drainage coming from the nose. Based on these findings the nurse determines that this client has an ineffective airway clearance related to copious amounts of thick secretions and proceeds to perform nasopharyngeal suction to relieve some of the secretions. If the nurse were documenting the evaluation of this intevention, what would be documented?

The amount and type of drainage suctioned from the nares, and the client's response The amount and type of drainage and the client's response to the nasopharyngeal suction is the evaluation and should be documented. The client's symptoms are documented as part of the assessment, ineffective airway clearance is documented as the nursing diagnosis, and nasopharyngeal suctioning is documented as the intervention.

A nurse is caring for a post-operative client 1 day after a total abdominal hysterectomy. Which nursing intervention demonstrates caring?

assisting the client to sit up in a chair

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.

The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using:

intuitive problem identification. Experienced nurses are able to make clinical decisions based on intuition, or an "inner prompting or hunch" that can lead to early and life-saving interventions. Intuitive problem solving is based on a background of experience, knowledge, and skill.

Use of the nursing process in health care allows the nurse to address the needs of the client. The nursing process:

provides a universally applicable framework for nursing activities.

A maternity nurse is teaching a first-time mother how to breast-feed her infant. The mother is having difficulty getting her infant to "latch" and tells the nurse, "At this rate, I don't think this is ever going to work out." According to Weiner's Attribution Theory, the nurse should respond in what way?

"Breast-feeding is natural, but it's often not easy. Let me show you how to get a better latch." When patients blame themselves for a learning deficit, the nurse can deflect this attribution by offering an alternative explanation (". . . it's not easy") and offering to teach. None of the other listed responses moves the teaching and learning process forward.

A maternity nurse is using a humanistic approach when teaching a new mother about breast-feeding. What question should the nurse use when implementing this approach?

"What is it that you'd most like to learn about breast-feeding?

When developing a nursing plan of care and associated client outcomes, which should the nurse recognize? Select all that apply.

A plan of care should be comprehensive, including the initial, ongoing, and discharge planning. Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care.