PrepU Chapter 11 Critical Thinking
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 previous admission record Client's children Client Client's physcian Client's caregiver
Client's children Client's caregiver Client's physcian 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.
The nurse is caring for a client in a critical care unit. The client's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm?
Cognitive and technical skills Explanation: The nurse used cognitive and technical skills to interpret this cardiac rhythm. Cognitive and technical skills equip nurses to manage the clinical problems stemming from the client's changing health or illness state. Interpersonal and ethical skills are essential for concerns related to the client's broader well-being.
A nurse is presenting a refresher program to a group of nurses who are returning to the workforce. When describing the nursing process to the group, which characteristic would the nurse most likely include? Select all that apply.
Collaborative Interpersonal Universally applicable Explanation: The nursing process is cyclical and dynamic, interpersonal and collaborative, and universally applicable.
A nurse has gathered data through interview, observation, and physical assessment of a client and has formulated diagnostic statements. What would the nurse do during the outcome identification phase?
formulate client-focused goals Explanation: During the outcome identification stage, the nurse should formulate client-focused goals that are measurable and realistic. Analyzing assessment information and performing diagnostic validation are completed during the diagnosis phase. Establishing nursing interventions is completed during the planning phase.
A client presents to the emergency room reporting weight gain, respiratory crackles, productive cough, and shortness of breath. The nurse demonstrates the implementation phase of the nursing process by performing which action?
inserting a peripheral IV and urinary catheter Explanation: Implementation is a measure that the client and nurse use to accomplish outcome criteria. The action of inserting a peripheral IV and urinary catheter is an example of implementing a specific treatment measure. The other actions demonstrate other phases of the nursing process - assessment, planning / goal-setting, and evaluation.
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. Explanation: 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. Acute observation ability is using skills to determine the extent of the issue using observation. Logical fallacies (illogical thinking) are used to describe faults in logic that result in false conclusions. Assumption a thing that is accepted as true or as certain to happen, without proof.
A nursing student is writing a paper for a class assignment and is integrating critical thinking skills. While reviewing the paper, the student asks himself which question to ensure that the breadth of the subject matter has been covered?
"Is there another way to look at the question?" Explanation: Figuring out another way to look at the question addresses the breadth of the subject matter. Expressing the point in another way reflects clarity. Finding out if the statement is true reflects accuracy. Addressing the implications does not necessarily determine whether the matter has been adequately addressed.
Which question asked by the nurse demonstrates proper understanding of a functional assessment?
"Can you bathe and dress yourself?" Explanation: A functional assessment is a comprehensive evaluation of the client's physical strengths and weaknesses in areas such as ADLs, cognitive abilities, and social functioning. Therefore, asking the client whether the client can bathe and dress independently is an example of the use of a functional assessment. The other questions represent other types of assessments, including database and focus assessments.
A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask?
"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.
Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)?
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.
Put the phases of the nursing process in the correct order.
Assessment Diagnosis Planning Implementation Evaluation Explanation: The correct order of the phases of the nursing process is: assessment, diagnosis, planning, implementation, and evaluation.
A nursing student is practicing to develop critical thinking skills specifically in the area of theoretical knowledge. With which activity would the student most likely be involved?
Active reading Explanation: The nurse can develop theoretical knowledge by active reading, studying, and writing. Experimenting in a lab improves technical skills. Working in a hospital improves both interpersonal as well as technical skills. Interpersonal skills can be gained through group work.
A nurse working on the unit questions an intervention after determining that the intervention was unsuccessful. The nurse is demonstrating which stage of skill acquisition?
Advanced beginner Explanation: An advanced beginner learns to consider more facts and complex rules, such that if an intervention is unsuccessful, the nurse may question the rule that was followed. At the novice stage, the nurse uses rules to guide practice. At the competence stage, the nurse devises new rules and reasoning procedures. At the proficient stage, the nurse realizes that events, contexts, and client situations are as important as the nurse's individual resources.
Which is a characteristic of person-centered care?
It is a framework for providing care. Explanation: The model of person-centered care is a framework for providing care. The approach is not independent of other disciplines, but is interdependent with other disciplines such as medicine, physiotherapy, surgery, etc. The model can be used in all settings and is not limited to hospital settings. Person-centered care aims to provide specific care to people based on individual needs.
A nurse interviews a pregnant teenager and documents the answers on the client record. At the same time, the nurse responds to the client's concerns and makes a referral for counseling and maternity care. Of which characteristic of the nursing process is this an example? Systematic Outcome-oriented Dynamic Universally applicable
Dynamic Explanation: Although the nursing process is an orderly, systematic progression of steps, there is also great interaction and overlapping among the five steps. No one step in the nursing process is a one-time phenomenon. Each step flows into the next step. In some nursing situations, all five steps occur almost simultaneously and are considered dynamic. Dynamic is characterized by constant change, activity, or progress, as illustrated in this scenario, in which the nurse assesses the client, diagnoses (informally) the client's problems, and plans and implements interventions all in the same visit. Outcome-oriented describes the evaluation phase of the nursing process, which is not depicted in this scenario. Universally applicable is another characteristic not depicted in this situation.
When using the nursing process, the nurse notes that there is a great deal of overlapping of the steps, with each step flowing into the next. What is the term for this characteristic of the nursing process?
Dynamic Explanation: The nursing process is described as a dynamic process because the steps are not a stagnant process. The nurse moves from one step to the next, with steps overlapping at times; in some nursing situations, all five stages occur almost simultaneously. Interpersonal refers to the nurse working with the client, with the client being the center focus of care. Systematic refers to how the nursing process directs each step of nursing care in a sequential, ordered manner. The nursing process is universally applicable because it is a way of problem solving in any nursing care situation.
Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this follow-up with the client, the nurse is in which step of the nursing process?
Evaluation Explanation: Evaluation is the step of the nursing process in which the nurse evaluates the results of a nursing action. The nurse needs to determine whether the client's pain has been relieved and monitor for any untoward effects. Assessment is the first step, in which the nurse gathers all the information. Planning occurs after information is gathered and the nursing diagnosis is generated. Implementation is the activation of nursing interventions.
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 Explanation: The North American Nursing Diagnosis Association (NANDA)-International defines nursing diagnosis as "a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes." A medical diagnosis describes a disease, whereas a nursing diagnosis describes an individual, family, or group response to an actual or potential health problem. A nursing diagnosis provides the basis for selection of nursing interventions to achieve positive client outcomes.
Which statements about the nursing process are accurate? Select all that apply. It is an orderly way of solving client problems. It helps to emphasize the client's active role in making decisions. It is important for providing individualized care to each client. It is essential for identifying medical diagnoses. It focuses on the care of adult clients.
It is important for providing individualized care to each client. It is an orderly way of solving client problems. It helps to emphasize the client's active role in making decisions. Explanation: The nursing process is an orderly, systematic, problem-solving approach to giving individualized care. Nurses use it in all settings with clients of all ages to identify and treat human responses to potential and actual health problems, not to identify medical diagnoses. It requires the nurse to incorporate the uniqueness of each individual, leading to individualized care. The nursing process also complements the current role of consumers in health care, in which clients play an active role in decisions affecting their health.
The client is admitted with multiple injuries, including a head injury, fractured ribs, and hypoventilation. Vital signs are: BP 110/84, T. 98.8/37.1, P. 88, Resp. 28. Which is the patient care priority?
Maintain an open airway. Explanation: A patent airway is always the priority of nursing care, particularly for clients with a head injury and hypo-ventilation.
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.
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.
The nurse is caring for a 35-year-old client who recently underwent gastric bypass surgery. The client is reporting horrible diarrhea. After a lengthy discussion, the nurse identifies that spicy food may be contributing to this problem. The nurse speaks with the staff nutritionist to work with the client to make appropriate food choices. Which best describes the nurse's discussion with the client?
Primary source information gathering Explanation: The client is always considered the primary source of information. Primary information is obtained through interview, examination, laboratory, and diagnostic findings. Secondary information is obtained via sources external to the client such as family members or outside health records. This scenario does not reflect the implementation or evaluation phase of the nursing process.
Which interpersonal skill is essential to the practice of nursing?
Promoting the dignity and respect of clients as people Explanation: Characteristics of interpersonal caring that are essential to the practice of nursing include promoting the dignity and respect of clients as people, the centrality of the caring relationship, and mutual enrichment of both participants in the nurse-client relationship. Keeping emotional distance is not part of the caring component of nursing. Keeping clients' personal information confidential is an ethical and legal skill. Performing technical skills is essential, but technical skills are not interpersonal skills.
In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged?
Reevaluating experience in light of ideas Explanation: Reflection at the higher level includes reevaluating experience in the light of ideas, behavior, feelings, and values. Reflection at the basic level includes recalling the sequence of events, identifying a positive situation, and thinking about relationships involved.
While interviewing a client diagnosed with cirrhosis of the liver, the nurse asks about alcohol consumption. The client is hesitant to give information. What would be most appropriate for the nurse to do?
Rephrase the question in a more acceptable form. Explanation: The nurse should rephrase the question in a more acceptable form if the client is hesitant to answer. Avoiding further discussion of the topic is inappropriate because alcohol use disorder is an important factor in liver disease. Requesting that the client answer the question and explaining the importance of the question may not help because it may make the client anxious and block communication.
Which statement is true of the nursing process? Trial-and-error problem solving is incongruent with the nursing process. It is more appropriate in medical surgical settings than community health care. Scientific problem solving can occur within the nursing process. It is a valid alternative to using intuition to respond to nursing situations.
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, trial-and-error, and intution may all take place within 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.
A group of nursing students is reviewing information about assessment and sources of information. The students demonstrate a need for additional review when they identify what as a secondary source?
The client Explanation: The client is the primary source of data. Secondary sources of information include family members, significant others, other health care professionals, health records, investigation reports, and literature review.
The client presents to the emergency room reporting chest pain and one episode of vomiting. Which action represents the nurse assessing the client? applying the client's therapeutic options acquiring vital signs and pain level identifying the client arranging the client's treatment and care
acquiring vital signs and pain level Explanation: Assessment involves collecting data/facts, such as by acquiring vital signs and pain level. The other actions demonstrate phases of implementation, evaluation, and planning.
A nurse admits a client who has diabetes and a blood glucose value of 600 mg/dl. What is the priority nursing action?
assessing the client for other signs of hyperglycemia Explanation: Assessing the client for other signs of hyperglycemia is the priority action that the nurse should perform for a client who has diabetes and a blood glucose value of 600 mg/dl, as this value is outside the normal range. It is not as urgent to determine post-insulin orientation, or develop a discharge plan. Reducing blood glucose within 4 hours is an example of implementation, which comes after the assessment in the nursing process.
A 56-year-old male client is admitted to the coronary care unit with a diagnosis of myocardial infarction. He is on a cardiac monitor and has an IV of D5W at a "keep open" rate. The nurse's priority concern is to assess:
chest pain. Explanation: The nurse's priority is to assess the client for chest pain. The presence of chest pain will affect the vital signs, P will increase, and BP will drop. With the cardiac monitor, the apical pulse rate is not a priority.
The nurse notes that the client has had a 20 mm Hg drop in systolic blood pressure in the past hour. The client is slurring words and cannot state the current date. The client has twice asked to speak with a parent, whom the nurse knows to be deceased. The nurse surmises that the client is acutely disoriented, and as such approaches an experienced nurse to ask for assistance. The nurse's thought process and actions in this scenario can best be described as:
clinical reasoning. Explanation: Clinical reasoning occurs when a nurse applies textbook knowledge to an actual client scenario. In this case, the nurse recognizes a drop in blood pressure and the inability to orient to person, place, and time as signs of clinical deterioration. This nurse is also building a clinical experience base, practicing astute nursing, and collaborating with the more experienced nurse.
The nurse is devising a problem-focused nursing diagnosis statement for a client. Which nursing diagnosis is problem-focused?
migraine related to caffeine detox as manifested by chills and vomiting Explanation: A problem-focused nursing diagnosis consists of the PES. "P" stands for the health related issue or problem. "E" stands for the etiology or cause. "S" stands for the signs/symptoms or defining characteristics. The name of the nursing diagnosis is linked to the etiology with the phrase "related to," and the signs/symptoms are identified with the phrase "as manifested by." The other statements do not contain all elements of the PES method.
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. Explanation: This statement is an outcome statement that focuses on the client, is realistic, and is measurable. Subjective data would include information from the client, such as complaints or reports of 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).
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:
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.
After developing the plan of care for a client, the nurse implements that plan. What would the nurse most likely use to implement it?
technical skills Explanation: During the implementation phase, intellectual, interpersonal, and technical skills are used. Awareness of clinical research and knowledge of care standards are important aspects of the planning and the evaluation phase of the nursing process. Observation is an important requirement in the assessment phase for collecting data.
A group of student nurses is working on developing various nursing skills and are at various stages of skill acquisition. The instructor determines that which student is at the novice stage?
the student who uses rules to guide practice Explanation: During the novice stage of skill acquisition, the learner uses rules to guide practice. The learner considers more facts and rules during the advanced beginner stage. At the competence stage, the learner feels responsible for outcomes. The learner knows the goal and how to achieve it at the expert stage.
Critical thinking is important in making an effective nursing judgment. Which technique would be most effective for the nursing student to adopt to improve classroom success?
turn errors into learning opportunities Explanation: The nurse should turn errors into learning opportunities to improve classroom success. This is especially important to allow nurses to synthesize their cognitive and physical learning to develop their critical thinking skills. Improving reading and writing skills, building a glossary of new words, and practicing active listening helps to improve the basic skills used in listening, studying, and thinking. Asking for assistance is often beneficial and should not be avoided.
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 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.
The nurse uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill?
Cognitive skill Explanation: The nurse is demonstrating the use of cognitive skills, which are characterized by identifying scientific rationales for the client's plan of care, selecting nursing interventions that are most likely to yield the desired outcomes, and using critical thinking to solve problems. Technical skills focus on manipulating equipment skillfully to produce the desired outcome. Interpersonal skills are used to establish and maintain a caring relationship. Ethically and legally skilled nurses conduct themselves in a manner consistent with their personal moral code and professional role responsibilities.
A nurse manager is talking with a new nurse. The nurse manager determines that the new nurse is thinking critically based on which statement?
"If I give this medication, the client probably will be sleepy." Explanation: Critical thinking requires the nurse to anticipate what will be next; for example, when giving the medication, the client will probably get sleepy. Critical thinking is also promoted by replacing statements such as "I don't know" and "I'm not sure" with statements and actions to seek out the answer. Lacking the knowledge about "why" does not reflect critical thinking. As stated, critical thinking involves trying to find out the answer.
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?
"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 statement made by the nurse indicates data that would be documented as part of an objective assessment?
"The client's right leg is cold to the touch, from the knee to the foot." Explanation: Objective data are information that is observable and measurable, such as observing that the client's right leg is cold to the touch. Subjective data relate to phenomena that only the client can experience, such as unrelieved pain, nausea, or heartburn.
What nursing organization first legitimized the use of the nursing process?
American Nurses Association Explanation: Although the term "nursing process" was first used by Lydia Hall in 1955, and nursing theorists delineated specific steps in a process approach to nursing, use of the nursing process was legitimized in 1973, when the American Nurses Association's Congress for Nursing Practice developed Standards of Practice to guide nursing performance. The National League for Nursing is a national organization for faculty nurses and leaders in nurse education. The International Council of Nurses is a federation of more than 130 national nurses associations. State boards of nursing accredit nursing schools.
A nurse demonstrates critical thinking when applying the nursing process to client care. Which behavioral components would the nurse likely use during the assessment phase? Select all that apply. Exploring ideas Asking relevant questions Recognizing assumptions Interpreting evidence Recognizing issues
Asking relevant questions Exploring ideas Recognizing issues Explanation: During assessment, the nurse asks relevant questions and explores ideas, validates data, and recognizes issues and concerns. Interpreting evidence and recognizing assumptions are behaviors associated with the diagnosis phase.
Which action would the nurse perform in the assessment phase of the nursing process?
Asking the client whether the client has cultural preferences Explanation: Assessing the client involves gathering information about the client's physical and emotional health; cognition; spiritual, cultural, or religious preferences; and sociodemographics. Developing a plan to manage the client's health problems falls within the planning phase of the nursing process. Coming up with the nursing diagnosis falls within the diagnosing phase of the nursing process. Determining whether the client's goals for wellness have been met occurs in the evaluation phase of the nursing process.
A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client?
Asking whether the client feels less anxious 30 minutes after administering the medicine Explanation: Evaluation allows the nurse to determine whether the client has met the goal. By analyzing the client's response to the anxiolytic, the nurse determines the effectiveness of the nursing care. The other actions demonstrate other parts of the nursing process: assessment (collecting data about the client's history with anxiety), diagnosis (assigning the client a new nursing diagnosis based on the client's controlled anxiety), and planning (devising a plan for the client to practice anti-anxiety exercises at home).
Which step in the nursing process includes the careful taking of a history and a nursing examination?
Assessment Explanation: Assessment is the careful observation and evaluation of a client's health status, which includes a thorough health history and nursing examination. During the nursing diagnosis, the nurse reports or analyzes data (according to level of practice) to identify and define problems. Planning involves several steps: setting priorities, defining expected or desired outcomes or goals, determining specific nursing interventions, and recording the plan of care. Implementation involves carrying out the written plan of care, performing the interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments.
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 Explanation: During assessment, the nurse recognizes the existence of cues and conducts a focused data collection. During diagnosis, the nurse clusters cues, interprets the clusters, and validates the diagnoses for accuracy. Planning involves preparing a client plan of care, which directs the activities of the nursing staff in the provision of care. Implementation is the action phase of the nursing process.
A nurse is caring for a 50-year-old client who has just undergone a hysterectomy and whose care is complicated by a postoperative infection. The client is on IV antibiotics. The nurse recalls from a literature review that probiotics are an effective means to prevent thrush in clients receiving antibiotics. This is an example of which phase of the nursing process?
Assessment Explanation: The nursing process includes assessment, diagnosis, planning, implementation, and evaluation. The nurse is assessing relevant information to formulate a nursing diagnosis and plan interventions for the client. Information obtained from the literature is an example of a secondary source of information.
A nurse demonstrates clinical reasoning during which phases of the nursing process? Select all that apply. Implementation Diagnosis Planning Assessment clinical judgement Evaluation
Assessment Diagnosis Planning Implementation Evaluation Explanation: All parts of the nursing process require clinical reasoning: assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Clinical judgment is developed when the nurse utilizes the process.
A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation?
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.
Which are characteristics of a critical thinker? Select all that apply.
Being open to all points of view Resisting easy answers to client problems Thinking outside the box Explanation: Being open to all points of view allows for the critical thinker to consider all possibilities when problem-solving. Resisting easy answers provides the critical thinker the opportunity to explore all potential answers when problem-solving, as well as prioritization of the answers. Thinking outside the box encourages that the best possible answer to the problem is chosen, rather than relying on the same generic answer that may not work for every situation. Basing one's thinking on the opinions of others does not foster exploration of new ideas, nor does it foster critical thinking when problem-solving. Acting like a know-it-all prevents the acceptance of new ideas and collaboration. Accepting the status quo discourages the principles of critical thinking.
The nurse has entered the room of a newly admitted client who immediately reports feeling short of breath. After identifying this as the client's problem, the nurse uses the process of scientific problem solving. Place the steps in the order the nurse would follow.
Collect assessment data. Formulate a hypothesis. Make a plan for action. Perform hypothesis testing. Evaluate. Explanation: Scientific problem solving is a systematic, 7-step, problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation, resulting in conclusion or revision of the study.
Recording prioritized outcomes in the plan of care ensures which benefit?
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."
A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. Which behavior is the nurse demonstrating in the care of the client?
Critical reflectivity Explanation: Critical reflectivity (becoming aware of one's awareness and critiquing it) occurs when a person questions judgments and considers other ways of thinking about the situation. Thoughtful practice is caregiving to promote the humanity, dignity, and well-being of the client. Reflection in action requires the person to engage in exploring experiences to lead to new understandings and appreciations during the situation or during clinical practice. Reflective skepticism involves adopting an attitude of doubt about supposed truths.
What is a systematic way to form and shape one's thinking?
Critical thinking Explanation: Critical thinking is defined as "a systematic way to form and shape one's thinking. It functions purposefully and exactingly. It is thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned." Intuitive thinking is a feeling (a sense) that doesn't use rational processes such as facts and data. Intuition comes from years of knowledge and experience that allow a nurse to understand how clients and the world works. Trial and error is a fundamental method of problem solving. It is characterized by repeated, varied attempts that are continued until success or until the agent stops trying. Interpersonal values are the kinds of human relationships that are considered important by the client or nurse.
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. 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.
After examining a child 2 years of age and based on findings, the nurse identifies a potential problem with normal growth and development. Which step of the nursing process does this identification of a potential problem represent?
Diagnosing Explanation: After assessing the need for nursing care, the nurse clearly identifies client strengths and actual and potential problems in diagnoses, which is the step of diagnosing in the nursing process. Assessment is careful observation and evaluation of a client's health status. 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. 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 analyzes client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve. Which step of the nursing process is the nurse performing?
Diagnosing Explanation: Analysis of client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve is a function of the diagnosis step of the nursing process. Assessing involves collection, validation, and communication of client data. Implementation is carrying out the plan of care. Evaluating is measuring the extent to which the client has achieved the outcomes specified in the plan of care.
Which step of the nursing process involves reporting or analysis of data to identify and define health problems?
Diagnosis Explanation: During the second phase of the nursing process (diagnosis), the nurse reports or analyzes data to identify and define health problems that independent or physician-prescribed nursing actions can prevent or solve. Assessment is careful observation and evaluation of a client's health status. 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.
The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process?
Diagnosis Explanation: The diagnosis phase involves the analysis of information and deriving the meaning from the analysis. The planning phase involves preparing a care plan and directing the nursing staff in providing care. The implementation phase involves initiation, evaluation of response to the plan, record of nursing actions, and client response to actions. Outcome identification involves formulating and documenting measurable, realistic, client-focused goals.
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?
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.
Which is an important element of implementation? Nursing orders Client database Critical thinking Documentation
Documentation Explanation: An important element of implementation is documentation. The client database includes all the information that is obtained from the medical and nursing history, physical examination, and diagnostic studies, which are more closely related to assessment and diagnosis rather than implementation. Critical thinking is intentional, contemplative, and outcome-directed thinking that is useful throughout the nursing process and not specifically an element of implementation. Nursing orders are specific nursing directions provided so that all health care team members understand what to do for the client; therefore, these are not an important element of implementation.
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 Explanation: A central aspect of a nurses'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.
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.
A nurse administers medications to a client. Which step of the nursing process would the nurse perform next?
Evaluating Explanation: The five systematic steps of the nursing process are assessment, diagnosing, planning, implementation, and evaluation. Implementation means carrying out the written plan of care and performing interventions, such as administering medications. Evaluation of client goals follows implementation of nursing interventions. If interventions have been effective, the client goal has been met. Assessing is the first step in which data is collected. Diagnosing is the second step in which the client problem, that the nurse is able to treat, is identified. Planning occurs after identification of the nursing diagnoses.
The nurse, working on a rehabilitation floor, has obtained a pair of crutches for a client from the physical therapy department. The nurse and the client set a goal of using the crutches twice daily to ambulate down the hall. However, at the end of the day, the client was only able to ambulate one time because the crutches were the incorrect height. The client's inability to ambulate best represents which phase of the nursing process?
Evaluation Explanation: This example illustrates several phases of the nursing process. The nurse evaluated that the plan of ambulating twice that day was unsuccessful. Critical thinking enables the nurse to determine that the equipment does not properly fit the client and must be adjusted or replaced if the goal is to be met. The nurse's next step is to revise the plan based on this evaluation. This scenario does not reflect the diagnosis phase of the nursing process, except that the client is learning a new skill.
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 Explanation: During the physical exam, the nurse uses the techniques of inspection, percussion, auscultation, and palpation. Interviewing is part of the history where the nurse gathers data about the client's functional health, including perception and interpretation of problems.
Which statement best conveys the role of intuition in nurses' problem solving?
Intuition can be a clinically useful adjunct to logical problem solving. Explanation: Creative, intuitive thinking can be useful supplements to more "in-the-box" methods of problem solving. While it should not be discouraged outright, it should also not be thought of as a replacement for logical or scientific problem solving. Intuition is not dependent on a special "gift" but is thought to be a product of experience and unconscious pattern recognition.
Which statement regarding critical thinking in nursing is true?
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.
Which are characteristics of critical thinking? Select all that apply. It requires a conscious and deliberate effort. It forms the basis for interdependent but not independent decision making. It is a habit that most nurses have learned in their education. It involves judgments based on evidence. It requires a systematic and logical approach
It requires a conscious and deliberate effort. It requires a systematic and logical approach It involves judgments based on evidence. Explanation: Critical thinking requires a conscious, deliberate effort. With repetition, critical thinking will become a habit, with nurses gaining expertise over time; it is typically not devoloped primarily during a nurse's formal education. Critical thinking also underlies independent and interdependent decision making and requires a systematic and logical approach, with judgments based on evidence.
The nurse is assigned the care of four elderly clients.Mr. A: 90 years of age. He suffered a stroke 7 days ago and is to be transferred to the rehabilitation unit today by 1000.Mr. B: 67 years of age, upset as he did not sleep all night because of chest pain, and admission to the unit at 0400 from emergency.Mr. C: recovering from abdominal surgery 2 days ago. He is to be discharged later today.Mr. D: admitted for regulation of high blood pressure and "inappropriate behavior". His wife of 45 years died 2 weeks ago. He is quiet and sleeping when the nurse arrives.Arrange the clients in the order the nurse would assess them.
Mr. B Mr. A Mr. C Mr. D Explanation: The nurse's assessment should proceed from the client with the most acute need and interventions. Mr. B is the most acute and needs to be assessed for chest pain. Mr. A is next because you need to have him ready for transfer by 10 a.m. Then Mr. C, who will need assessment for any discomfort and discharge teaching. Finally, Mr. D, who is resting but will need BP monitoring and ongoing assessment and comfort measures.
Benner (2000) has developed a model of skill acquisition outlining the stages of increasing expertise. How would the practitioner who uses rules to predominantly guide practice be described?
Novice Explanation: Benner's model progresses from novice, advanced beginner, competent, proficient, to expert. The novice must rely on rules and guidelines to guide clinical judgment. The novice does not yet have the clinical expertise to use previous experiences to think outside of the box or challenge findings to determine the best action.
Place the stages of skill acquisition listed below in the proper order from first to last.
Novice Advanced beginner Competence Proficient Expert Explanation: The model of skill acquisition follows these stages. The first stage is novice, in which learners use rules to guide practice. Examples of such rules include information and skills that you learn from instructors, practice in laboratory, and read in books. Advanced beginner is the next stage. After more experience in clinical situations, nurses learn to consider more facts and complex rules. If an intervention is unsuccessful, the nurse may question the rule that was followed. At competence, nurses devise new rules and reasoning procedures. They feel responsible for the outcomes and may question rules. Nurses gain competence through more experience. As situations become complex, nurses assimilate experiences and implement plans. As nurses become proficient, they realize that the events, context, and client situation are as important as the nurse's individual resources. Based on the evaluation, nurses develop and implement future actions. The actions become easier. The outcomes become more important than the interventions. Thinking is more flexible and intuitive rather than planned and deliberate. The last stage is expert. The expert knows the goal to achieve and how to achieve it. The best experts think before they act. They intuitively use sound theoretical thinking to reflect on the goal and decide on the seemingly appropriate action. They avoid getting caught in one perspective. The expert can link theory, practice, and intuition. This is the goal.
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 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.
The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case?
Obtaining data regarding the amount and frequency of drinking Explanation: A focused assessment is information that provides more details about specific problems and expands the original database. Obtaining data regarding the amount and frequency of drinking qualifies as a focused assessment. The other actions do not relate to the client's drinking habits or potential for alcohol overuse and thus would not be included in a focussed assessment of these issues.
A nurse formulates a plan of care for a client who has experienced a stroke. What would the nurse do to establish accurate nursing diagnoses for this client?
Perform cluster interpretation. Explanation: The nursing diagnostic process uses cue clustering, cluster interpretation, and diagnostic validation to ensure accuracy in selecting the correct diagnoses. Identifying intervention strategies, performing reassessment, and evaluating the client's response are inappropriate activities to ensure accuracy of nursing diagnoses. Identifying intervention strategies is an activity performed when preparing the care plan for the client once the diagnoses and outcomes have been identified. Reassessment and evaluation of the client's response are carried out in the implementation phase of the nursing process.
Which step in the nursing process is most closely associated with cognitively skilled nurses?
Planning Explanation: Cognitively skilled nurses are critical thinkers and are able to select those nursing interventions that are most likely to yield the desired outcomes, which occurs in the planning stage of the nursing process. Assessment requires a combination of interpersonal and technical skills in gathering objective and subjective data. Implementation relies heavily on technical, psychomotor, and teaching/communicating skills. Evaluation requires critical thinking, as well, in evaluating how well the plan of care was implemented and whether changes occurred, but not as much as planning, in which the outcomes that are measured in the evaluation phase are developed.
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?
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 home health nurse reviews the nursing care plan with the client and family. Then they mutually discuss the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?
Planning Explanation: During the planning step, the nurse identifies expected outcomes of the plan of care. The plan of care should be holistic and individualized, specify desired client goals and related outcomes, and identify the nursing interventions most likely to meet those expected outcomes. Assessment is careful observation and evaluation of a client's health status. 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. 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 has measured from the tip of the client's nose to the 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 Explanation: Determining the correct length of the NG tube to insert is an example of the planning that is necessary to conduct this nursing action. The actual insertion of the NG tube would constitute implementation. Assessment would be checking that after insertion, the NG tube is properly working. Diagnosing is gathering the evidence that the client needs an NG tube. Evaluation would be determining whether the outcome associated with inserting the NG tube has been accomplished.
For a new nurse, what is essential to the mastery of technical skills, such as giving an injection?
Practice performing the skill in a safe environment until comfortable doing it. Explanation: Before attempting to perform a technical skill with or on a client, the nurse must practice that skill until the nurse feels confident doing it. Practicing the skill in a safe environment is recommended prior to performing the skill on a client. Telling the instructor that the nurse will never be able to give an injection is not appropriate. Nurses are expected to perform a variety of skills in the health care setting. The nurse should not pretend to know what to do if the nurse does not feel comfortable performing the skill. The nurse should read the steps for the injection process prior to practicing the skill, but the practicing is what is essential to mastering the skill.
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 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 are characteristics of one who has developed critical thinking skills?
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.
After completing an assessment of a client, which finding should the nurse determine is the priority for care? Severe bleeding from a wound History of asthma Diabetes Lack of family support
Severe bleeding from a wound Explanation: The client's problem is considered to be of high priority if it is life threatening, requires more intervention time, or has serious consequences. The severe bleeding from a wound would be the highest priority. The client's history of asthma, diabetes, and lack of family support may be important, but the bleeding is the priority.
A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which aspect of the nurse's execution of this order demonstrates technical skill?
Starting a new, large-gauge intravenous site on the client and priming the infusion tubing Explanation: Performing tasks that require manual dexterity is a manifestation of technical skills. Explaining the transfusion process largely depends on interpersonal skills, whereas understanding the theory behind blood types is indicative of cognitive skills. Informed consent lies within the domain of legal/ethical skills.
Which statements describe the common use of problem-solving in the nursing process? Select all that apply. The trial-and-error problem-solving method is used extensively in the nursing process. Today, nurses acknowledge the positive role of intuitive thinking in clinical decision making. 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. Nurse theorists and educators advocate basing clinical judgments on data alone to establish nursing as a science, worthy of the respect of other professions. Critical thinking in nursing can be intuitive or logical or a combination of both. The trial-and-error problem-solving method is recommended as a guide for nursing practice.
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. 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. Explanation: The scientific problem-solving method is a systematic 7-step problem-solving method that may be used in conjunction with the nursing process. Intuitive thinking and clinical decision making use intuitive problem solving as a direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible. Logic provides a safer approach to decision making, but intuition provides a creative approach to decision making; therefore, a combination of both is a part of the nursing process. Trial-and-error is not used extensively in the nursing process because it involves testing any number of solutions until finding one that works for that particular problem, which can be dangerous for the client.
What is the most important reason for the nurse to develop critical thinking and clinical reasoning?
To provide quality care with nursing ability and knowledge Explanation: The goal of all nursing is to meet the standard of quality care. All of the answers contain valid reasons for developing clinical reasoning and critical thinking, but the most important goal in health care is to provide quality nursing care to clients. The nursing licensing examination is a an exam to assess the safety of nursing care using critical thinking for a generalist who graduates from a nursing program. The nursing process guides the development of care plans using critical thinking in the process. Over time, a beginning nurse develops into an expert nurse.
Which scenario represents a nurse demonstrating the critical thinking process? collaborating with the respiratory therapist and physical therapist to address a complication using power for more control and freedom over the daily tasks assessing whether physician help is needed assessing why a physician encounter form is missing from the record
assessing whether physician help is needed Explanation: Critical thinking involves consistency, relevancy, and logical thinking. It enables the nurse to make decisions. Therefore, assessing whether physician help is needed is an example of the critical thinking process. The other actions support other nursing soft skills.
The Canadian Nurses Association (CNA) has published the standards of care for which the nurse is responsible. The Standards of Practice are:
assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Explanation: The CNA's six Standards of Practice are assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The nursing process encompasses all significant nursing actions and forms the foundation for the nurse's decision making.
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. 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.
Which nursing actions should the nurse document as objective data?
measuring the client's blood pressure recording whether or not the client has vomited observing the client's skin color Explanation: Objective data is observable and measurable, such as measuring blood pressure values, recording episodes or the absence of vomiting, and observing the client's skin color. Subjective data consists of information that the client can describe or experience, such as pain and fatigue.
A nurse working in an outpatient surgery center is responsible for taking a health history and performing a physical assessment on each client scheduled for surgery. Why is establishing this database so important for patient care?
to identify strengths and problems Explanation: Without a complete and accurate database, it is impossible for the nurse to identify client strengths and problems. Assessing and establishing a database is the first step in the ordered sequence of events in the nursing process. The care team's time is not the focus. This assessment is an opportunity for establishing rapport, but this is not the primary purpose.
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. Explanation: The nursing process requires blended skills and critical thinking. Critical thinkers think systematically about the nursing process and apply it for the individual client. Communication is important but not sufficient to meet client needs, and scientific problem solving is used in the laboratory setting, not nursing.
Nurses use the nursing process to plan care for clients. In which cases is the nursing process applicable? Select all that apply. when nurses work with clients who are able to participate in their care when families are clearly supportive and wish to participate in care when clients are totally dependent on the nurse for care when families are not supportive and do not wish to participate in care.
when nurses work with clients who are able to participate in their care when families are clearly supportive and wish to participate in care when clients are totally dependent on the nurse for care when families are not supportive and do not wish to participate in care. Explanation: The nursing process is used in all nursing care situations. This includes working with clients and families who are able and willing to participate in their care, and working with clients who are not able to participate in their care because of being totally dependent on the nurse for care.
