Chapter 2- Critical Thinking in Health Assessment

Nursing diagnoses

A nurse has completed a comprehensive assessment of a client and has begun the process of data analysis. Data analysis should allow the nurse to produce which direct result?

"It was done to validate the reading."

A client asks why a nurse measured the blood pressure after the nursing assistant completed the measurement a few minutes ago. What should the nurse respond to the client?

Make a referral to the dietician.

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse?

"It's acceptable for a client to be admitted for observation."

A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response?

Itchy feeling

A client presents to the clinic with reports of an itchy rash all over the body. The nurse observes lesions on the client's arms and legs as well as the presence of a dry, hacky cough and sneezing. Which data collected from the client can be classified as a subjective abnormal finding?

Place on cardiac monitor.

A client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse?

implementation

A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?

Wellness diagnosis

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information?

analyze the data

A nurse has just admitted a client who has a wound infection to the unit. After assessing the client, the next step of the nursing process the nurse should perform is:

"What other symptoms occurred during the spell?"

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?

Schedule a dietary consult.

A nurse is teaching a client newly diagnosed with diabetes about diet and the exchange list. After several teaching sessions, the client continues to be confused and not sure about what to eat. The nurse's next best action is which of the following?

Inflamed appendix is causing severe abdominal pain.

A nurse is writing down hunches about certain cue clusters related to a client. Which of the following hunches would seem to indicate the need to generate a collaborative problem as opposed to a nursing diagnosis?

Overlooking consideration of the clients cultural background

A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case?

Critical thinking is the foundation of the process of diagnostic reasoning.

An experienced medical-surgical nurse has identified critical thinking as an integral component of diagnostic reasoning. How can the relationship between these two concepts be best described?

Health promotion diagnosis

During the assessment interview, the client made numerous statements that suggested his life generally exists in a state of harmony and balance. The nurse would document this as which type of nursing diagnosis?

Validate the collected data.

The emergency department has collected extensive data from a client who has presented with a new onset of severe abdominal pain. What nursing action should the nurse perform before proceeding with data analysis?

discuss the plan with the client

The nurse has completed an assessment on a new client. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to

Analyze the data

The nurse has learned that after completing the assessment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do?

Reassess blood pressure

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?

Assess the client further for evidence of reduced mobility and decreased range of motion.

The nurse is attempting to cluster the data collected during the initial assessment of an older adult client. The nurse notes that the client had a swollen left knee and complained of "a bit of soreness" in the joint, but the nurse does not have enough data to support a nursing diagnosis of Impaired Physical Mobility. What should the nurse do next?

planning

The nurse is developing goals after completing the assessment of a newly admitted medical client. The nurse would document the goals under which part of the nursing process?

Wellness

The nurse is working with a 14-year-old girl who has told the nurse that she would like to try getting to bed a little sooner to get a full night's sleep and have more energy at school. The nurse diagnoses her with the following: Readiness for enhanced sleep related to client's expressed desire to go to bed earlier. Which type of nursing diagnosis is this?

Wellness

The nurse notes the diagnosis "Readiness for enhanced coping" written on a client's care plan. What type of diagnosis has been identified for the client?

Family history

The nurse prepares a genogram after collecting health history information from a client. For which part of the history is this diagram beneficial?

analyzing the data

The nurse understands that, after clustering data and drawing inferences, if the problem is something a nurse could manage independently the next step would be which of the following?

Thyroid isthmus barely palpable, lobes not felt

When documenting clinical data after an assessment of the client's neck, what might you write in the physical assessment?

Maintenance of an open mind

Which of the following would be most important for a nurse when developing critical thinking skills?

client ambulated 3/3 times during a planned 8-hour period

Which statement would demonstrate the correct method for writing an evaluation of client progress after implementing the nursing process?

None currently.

Your client has been directly admitted from the doctor's office. The only paperwork he has brought with him is his admission orders. You are gathering your admission data when ordered lab work is collected. When documenting your history, physical examination, assessment, and plan, what would you write under the heading "Laboratory Data"?

It involves reflections on thoughts before reaching conclusions.

A hospital nurse has identified a need to improve her critical thinking skills in an effort to improve client care. The nurse should identify which of the following characteristics of critical thinking?

It requires diagnostic reasoning skills.

A nursing instructor is describing why data analysis is considered a very difficult step in the nursing process. Which of the following would the instructor identify?

The looking at of the identified abnormal findings and strengths for cues that are related

An instructor is describing the steps of the diagnostic reasoning process to a group of students. The instructor is accurate when describing clustering data as involving which of the following?

Skin breakdown

In what area do nurses use formalized screening and assessment tools?

False

OLD CART is a mnemonic that will help the nurse remember the steps in the nursing process.

validate information and judgments.

One characteristic of a nurse who is a critical thinker is the ability to

too many or too few data

The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following?

nursing diagnosis

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?