Chapter 12: The Nursing Process and Critical Thinking

The statement "Turn from side to side every 2 hours. Get out of bed at least twice a day. Being ambulating as tolerated", refers to which component of documentation? 1. plan 2. assessment 3. evaluation 4. objective information

1. Plan

Which is a correct recording of observational data? 1. The skin is cool and clammy 2. The skin looks good 3. The patient states "my skin is cool and clammy" 4. The patient's skin has improved

1. The skin is cool and clammy

A female patient had a radical mastectomy of her left breast. Her husband was not supportive of her surgery. What is the priority initial nursing intervention for this patient? 1. assist patient to discuss changes caused by illness and surgery 2. monitor frequency of patient's statements of self criticism 3. determine patient's and family's perception of her alteration in body image vs. reality 4. identify available support groups

1. assist patient to discuss changes caused by illness and surgery

Which of the following are nursing diagnoses? 1. Constipation 2. Pneumonia 3. Insomnia 4. Myocardial Infarction 5. readiness for enhanced urinary elimination 6. impaired swallowing 7. risk for falls

1. constipation 3. insomnia 5. readiness for enhanced urinary elimination 6. impaired swallowing 7. risk for falls

A postoperative patient has just been transferred from the recovery unit to his bed on the medical floor. Which diagnosis is the highest priority for this patient? 1. risk for shock 2. risk for infection 3. risk for loneliness 4. risk for powerlessness

1. risk for shock

The nurse utilizes which critical thinking tool when considering possible outcomes of each nursing action and choosing one intervention? 1. Interpretation: identifying date 2. Evaluation: assessing possibilities 3. Inference: drawing conclusions 4. self-regulation: reconsidering conclusions

2. Evaluation: assessing possibilities

A 75 year old man is admitted to a long term care facility with weight loss and diarrhea. Which nursing diagnosis is the highest priority for this patient? 1. complicated grieving 2. dysfunctional gastrointestinal motility 3. impaired individual resilience 4. ineffective self care management

2. dysfunctional gastrointestinal motility

Which characteristics of critical thinking are related to analytical thinking? SATA. 1. willing to consider various alternatives 2. examines parts and sees how they fit together. 3. recognized that many variables are at work in patient situations 4. uses an organized approach to problem solving 5. the desire not just to know, but to understand, how to apply the knowledge 6. applies knowledge from various disciplines

2. examines parts and sees how they fit together. 6. applies knowledge from various disciplines

Which of the following describes critical thinking? 1. thinking based on learning many facts 2. reasonable thinking focused on deciding what to do 3. thinking based on the utilization of the nursing process 4. reflective thinking related to reading and gathering information

2. reasonable thinking focused on deciding what to do

A 72 year old patient admitted to the hospital takes a diuretic, an antihypertensive drug, and an anticoagulant. Which nursing diagnosis is the highest priority for this patient? 1. risk for acute confusion 2. risk for bleeding 3. risk for complicated grieving 4. risk for compromised resilience

2. risk for bleeding

The care plan states that the nurse is supposed to give the patient a bath. The patient states that he feels "wobbly" when he stands up. The nurse checks his blood pressure, which is 90/60 mm Hg and his pulse is 120 and weak. What is the best nursing action? 1. Try again to get him up 2. Give him a bed bath 3. Let him rest and see how he feels later 4. Exercise his legs before letting him stand

3. Let him rest and see how he feels later

Which of the following observations about the patient is documented as subjective data? 1. Patient is 6'3" tall and weighs 180 pounds. 2. Patient's skin is jaundiced. 3. Patient has pain associated with taking deep breaths 4. Patient's blood pressure is 130/80 mm Hg

3. Patient has pain associated with taking deep breaths

Which of the following short term goals is incomplete? 1. The patient will drink 1500 mL by 8:00am on 3/22 2. The patient will ambulate in the hall twice a day on 3/22 3. The patient will have less pain by 8:00am on 3/22 4. The patient will cough and deep breathe every 4 hours on 3/22

3. The patient will have less pain by 8:00am on 3/22

The role of the LPN in relation to the planning phase of the nursing process is to: 1. perform a physical assessment 2. perform therapeutic nursing measures 3. assist with the development of nursing care plans 4. evaluate the nursing care given

3. assist with the development of nursing care plans

Which of the following are related to hydration nursing diagnoses (2012-2014)? SATA. 1. functional urinary incontinence 2. diarrhea 3. deficient fluid volume 4. risk for electrolyte imbalance 5. readiness for enhanced fluid balance

3. deficient fluid volume 4. risk for electrolyte imbalance 5. readiness for enhanced fluid balance

Auscultation is used to assess the? 1. skin 2. joints 3. lungs 4. head

3. lungs

A patient is in the hospital with a pressure ulcer. The nurse documents on the chart "Does not turn self in bed; 2 cm, stage II pressure ulcer on sacrum." Which component of documentation is this? 1. Subjective data 2. Assessment 3. Plan 4. Objective Data

4. Objective Data

The nurse is presenting an in service education program on the nursing process. Which information should the nurse include about the goal of the nursing process? The goal of the nursing process is to: 1. obtain information through observation, physical examination, or diagnostic testing 2. interview the patient or family in a goal directed, orderly, and systematic way 3. record objective date, writing exactly what is observed 4. alleviate, minimize, or prevent real or potential health problems

4. alleviate, minimize, or prevent real or potential health problems

Why is auscultation done before percussion and palpation when doing a physical assessment of the abdomen? 1. auscultation aids in the palpation process 2. palpation can alter auscultation findings 3. auscultation can alter palpation findings 4. auscultation findings determine where to perform percussion

4. auscultation findings determine where to perform percussion

When admitting a patient with pneumonia, which step of the nursing process is done first? 1. implementation 2. determine outcome criteria 3. set short term goals 4. collect data

4. collect data

In the planning phase of the nursing process, which of the following actions occurs first? 1. set short term goals to determine outcomes of care 2. set long term goals to determine outcomes of care 3. develop objectives to meet goals 4. determine priorities from the list of nursing diagnoses

4. determine priorities from the list of nursing diagnoses

Which step of the nursing process does the nurse use to determine whether outcome criteria have been met? 1. assessment 2. planning 3. implementation 4. evaluation

4. evaluation

Which is the best method for obtaining objective data? 1. asking the patient about his pain 2. observing the patient to see if he is afraid 3. watching the patient for signs of fatigue 4. inspecting the color of the patient's skin

4. inspecting the color of the patient's skin

Which would the nurse chart under objective data? 1. lumbar back pain 2. nausea 3. no shortness of breath 4. pupils equal and reactive

4. pupils equal and reactive

In what level of Maslow's hierarchy does the nursing diagnosis of Disturbed body image fall? 1. physiological 2. safety 3. love and belonging 4. self-esteem

4. self-esteem

What is a patient's noisy and labored breathing a sign of? A. possible respiratory problems b. possible sign of diabetic ketoacidosis c. may indicate that patient is in shock d. may indicate inability to carry out self care activities at home

A. possible respiratory problems

Match definition with correct critical thinking tool: examining ideas and breaking them down into components

Analysis

Match definition with correct nursing process: collect data, including height, weight, and vital signs

Assessment

Match definition with correct nursing process: obtain information through a health history by direct questioning

Assessment

Match definition with correct nursing process: systematic collection of data relating to patients and their problems

Assessment

Match definition with term: Collection of data about the health status of a patient

Assessment

Match definition with term: Listening to sounds produced by the body, such as heart, lung and intestinal sounds

Auscultation

What technique best suits: Blood Pressure

Auscultation

What technique best suits: Bowel Sounds

Auscultation

What technique best suits: Lung Sounds

Auscultation

What is a patient's cold, clammy skin a sign of? A. possible respiratory problems b. possible sign of diabetic ketoacidosis c. may indicate that patient is in shock d. may indicate inability to carry out self care activities at home

C. may indicate that patient is in shock

What is a patient's disheveled appearance a sign of? A. possible respiratory problems b. possible sign of diabetic ketoacidosis c. may indicate that patient is in shock d. may indicate inability to carry out self care activities at home

D. may indicate inability to carry out self care activities at home

Match definition with correct critical thinking tool: assessing possibilities, opinions, and usual practices

Evaluation

Match definition with correct nursing process: Assessing the achievement of patient goals

Evaluation

Match definition with correct nursing process: measure the patient's progress toward meeting goals

Evaluation

Match definition with correct critical thinking tool: presenting arguments for decisions and justifying

Explanation

A new patient is admitted to the hospital with the following diagnoses: fatigue, nausea, ineffective individual coping, and ineffective breathing pattern. Which requires immediate attention?

Ineffective breathing pattern

Match definition with correct critical thinking tool: deriving alternatives and drawing conclusions

Inference

Match definition with term: Purposeful observation or scrutiny of the person as a whole and then of each body system

Inspection

What technique best suits: Cyanosis

Inspection

What technique best suits: Jaundice

Inspection

What technique best suits: Mucous Membranes

Inspection

Match definition with correct critical thinking tool: clarifying the meaning of events and data

Interpretation

Match definition with correct nursing process: Putting the plan into action

Intervention

Match definition with correct nursing process: actual performance of nursing interventions identified in the care plan

Intervention

Match definition with term: Systematic, problem solving approach to providing nursing care in an organized scientific manner

Nursing Process

Match definition with term: Actual or potential health problems derived from data gathered during the assessment of a patient

Nursing diagnosis

Match definition with term: Information about the patient collected through physical examination, diagnostic tests, and patient records

Objective Data

Match definition with term: Method of physical examination that uses the sense of touch to assess various parts of the body

Palpation

What technique best suits: Pitting edema

Palpation

What technique best suits: Radial Pulse

Palpation

Match definition with term: Tapping on the skin to assess the underlying tissues

Percussion

Match definition with correct nursing process: Setting goals

Planning

Match definition with correct nursing process: determine priorities from the list of nursing diagnoses

Planning

Match definition with correct nursing process: set short term and long term goals to determine outcomes of care

Planning

Match definition with term: Method of recordkeeping that focuses on patient problems rather than on medical diagnoses

Problem Oriented Medical Record

Match definition with correct critical thinking tool: reconsidering conclusions and recognizing the need to make changes

Self-regulation

Match definition with term: Information reported by patients or family members in response to questions or statements

Subjective Data

What is a patient's fruity mouth odor a sign of? A. possible respiratory problems b. possible sign of diabetic ketoacidosis c. may indicate that patient is in shock d. may indicate inability to carry out self care activities at home

b. possible sign of diabetic ketoacidosis

Match definition with correct nursing process: Identify health problems or potential health problems

nursing diagnosis

Match definition with correct nursing process: Interpretation of the data for problem identification

nursing diagnosis