Chapter 13

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

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

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

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

Reflection

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

uses critical thinking to direct care for the individual client.

The nurse is developing a plan of care for a client with a fractured femur 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 female client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client?

Administer a high-calorie diet, excluding wheat, rye, and oats.

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.

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 action best demonstrates the nursing skill of caring in this situation?

Assisting the client to sit up in a chair

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

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

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

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking?

Clarity

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. Use all options.

Collect assessment data. Formulate a hypothesis. Make a plan for action. Test the hypothesis. Interpret results. Evaluate.

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

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

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective.

A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment?

Document this assessment based on the client's behaviors.

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

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

Which are characteristics of reasoning? Select all that apply.

Is based on assumptions Has a purpose Contains inferences Has implications

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking.

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

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

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next?

Modify the plan of care and interventions to meet the client's needs.

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 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.

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.

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?

Repositioning the client

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client.

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

Put the phases of the nursing process in the correct order. Use all options.

assessment diagnosis planning implementation evaluation

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.

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 is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?

involving the client with all the steps of the process in care development

A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as:

life-sized mannequins with a sophisticated computer interface.

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.