Chapter 13: Blended Competencies, Clinical Reasoning and Processes of Person-Centered 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? Implementation Planning Diagnosis Assessment

Assessment

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? Establish a nursing diagnosis of Altered Skin Integrity. Report it to the health care provider. Assess the client's back visually. Document the rash in the client's chart.

Assess the client's back visually.

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? Weigh client as needed. Administer a daily multivitamin. Monitor for allergies. Administer a high-calorie diet, excluding wheat, rye, and oats.

Administer a high-calorie 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? Administer a prescribed medication to decrease the client's blood glucose level. Analyze the data and create an individualized nursing diagnosis. Identify outcomes for the client with the client's input. Follow up with the client later to determine whether the client's laboratory test results improve.

Analyze the data and create an individualized nursing diagnosis.

Which statements are true about the implementation phase of the nursing process? Select all that apply. Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health. All interventions carried out during this phase must be accompanied by a physician's order. Implementation is only carried out by nursing professionals. Care provided during implementation should be documented in the client's chart.

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? Taking a client's blood pressure on both arms at the beginning of a shift Recognizing that the client's blood pressure of 172/101 is an abnormal finding Checking the client's blood pressure 30 minutes after administering captopril Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading

Checking the client's blood pressure 30 minutes after administering captopril

Which action exemplifies the purpose of evaluation in the nursing process? Decide whether to continue, modify, or terminate client care. Determine the client's health status, self-care ability, and need for nursing. Develop a prioritized list of nursing diagnoses. Develop an individualized plan of client care.

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? Check the client's skin turgor. Administer an additional liter of intravenous fluids. Formulate a plan of care based on risk for dehydration. Determine whether the prescribed treatment was effective.

Determine whether the prescribed treatment was effective.

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? Implementing Planning Appraising Evaluating

Evaluating

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 Trial-and-error Scientific Experiential

Intuitive

Which students study the best in a group setting? Sensory learners Kinesthetic learners Auditory learners People-oriented learners

People-oriented learners

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? Implementation Evaluation Planning Diagnosis

Planning

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? Keep resolved nursing diagnoses as part of the plan of care in case the related problems return. Do not allow the client to review the client's own nursing diagnoses. Prioritize the nursing diagnoses. Add a new nursing diagnosis in the nurse's own words to individualize the plan of care.

Prioritize the nursing diagnoses.

Which is the best example of person-centered care provided by a registered nurse? Administration of pain medication every 4 hours to a client who is postoperative Reassuring a client who is anxious about a procedure Development of a plan of care for a new admission Insertion of a nasogastric tube for gastric decompression

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? Assess the skin for signs of cyanosis. Ask the parent whether the child has been exposed to cold temperatures. Cover the infant. Recheck the temperature, paying close attention to technique.

Recheck the temperature, paying close attention to technique.

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? During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. After turning the client alone, the nurse realizes that the nurse should have insisted on having help. Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. The nurse decides to turn the client every 4 hours because everyone is too busy to help.

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? Assessment Evaluation Memorization Reflection

Reflection

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 Surveillance Maintenance Technical Supervisory

Supervisory

A nurse is caring for a client with diabetes mellitus. The client takes insulin 2 times per day. The nurse makes sure the client's meals arrive in coordination with the insulin's effect. The knowledge used by the nurse is: integrated. evaluative. lacking. creative.

integrated

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. uses scientific problem solving to meet client problems. employs communication to meet the client's needs. applies intuition and routine care for clients.

uses critical thinking to direct care for the individual client.