Ch. 13

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?"

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

The nurse is caring for an underweight 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 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats

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?

Analyze the data and create an individualized nursing diagnosis.

A nurse is educating a pregnant client in preterm labor on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn?

Anxiety

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.

A nurse technician is assigned to take clients' vital signs. When making rounds, the nurse notices that one client's vital signs are very different from what they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings?

Assess the client's vital signs again.

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

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

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's caregiver Client's physcian Client's previous admission record

Which action exemplifies the purpose of evaluation in the nursing process?

Decide whether to continue, modify, or terminate client care.

A novice nurse is engaging in reflection. The nurse would most likely be involved in which action?

Describing the events

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 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 accountability

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

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

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

Diagnosis

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

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

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

Evaluation

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

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

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

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill?

Intellectual

Which is a characteristic of person-centered care?

It is a framework for providing care.

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking.

Which are characteristics of critical thinking? Select all that apply.

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

Which statements are true about informatics in nursing practice? Select all that apply.

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.

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

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

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

A nurse who is not familiar with using automated intravenous (IV) pumps is moving to a unit that 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?

Practice using the device under the supervision of a more experienced nurse before using it with a client.

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?

Prioritize the nursing diagnoses.

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

Which is the best example of person-centered care provided by a registered nurse?

Reassuring a client who is anxious about a procedure

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next?

Recheck the temperature, paying close attention to technique.

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

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?

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?

Reflection

Put the steps of the clinical reasoning cycle in the correct order.

Review current information. Analyze data to come to an understanding of signs or symptoms. Match current clients to past clients. Describe what the nurse wants to happen, a desired outcome, a time frame. Select a course of action between different alternatives available. Evaluate the effectiveness of actions.

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

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

What is the purpose of the diagnosis phase of the nursing process?

To develop a prioritized list of client-centered problems

The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use?

Trial-and -error problem solving

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.

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.

What result is the most appropriate outcome for the nursing diagnosis of Impaired Urinary Elimination? The client will:

maintain urine output of 30 mL/hr.

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.

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.

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

A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask?

"What happened?"

The nurse is providing education to a group of middle school students regarding cold weather safety. One of the students asks the nurse how cold her body will get when it is cold outside waiting for the school bus. The nurse responds:

"We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time."

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.

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

A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care.

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

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

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.

What is the best way for a nurse to obtain a full set of data when performing an assessment of a client?

Complete a systematic nursing history and nursing examination.

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

How can the nurse obtain a more complete database for a newly admitted client?

Comprehensive client assessment

Recording prioritized outcomes in the plan of care ensures which benefit?

Continuity of care can be provided to the client.

Which action should the nurse associate with outcome identification and planning in the nursing process?

Develops an individualized plan of nursing care

Which is an important element of implementation?

Documentation

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

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 intravenous antibiotics. The nurse begins to prepare for this admission. What type of problem solving does this exhibit?

Intuitive

Which are characteristics of reasoning? Select all that apply.

Is based on assumptions Has a purpose Contains inferences Has implications

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

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

Which intervention is most appropriate for a client newly diagnosed with diabetes and a nursing diagnosis of Deficient Knowledge?

Teach the client how to administer insulin.

The nurse is caring for a mother and newborn baby couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast feed. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the most appropriate action by the nurse at this time?

Terminate the plan of care because evaluation reveals that the outcome has been met.

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 suctioning to relieve some of the secretions. If the nurse were documenting the evaluation of this intervention, what would be documented?

The amount and type of drainage suctioned from the nares, and the client's response

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

The client has a normal temperature and no signs or symptoms of infection.