Clinical Judgement

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? "Moderate amount of drainage." "No change in drainage since yesterday." "A 10-mm-diameter area of drainage at 1900 hours." "Drainage is doubled in size since last dressing change."

"A 10-mm-diameter area of drainage at 1900 hours."

What is the nurse's primary consideration when caring for a client with rheumatoid arthritis? Surgery Comfort Education Motivation

Comfort

A nurse is assessing a client with Cushing syndrome. Which signs should the nurse expect the client to exhibit? Select all that apply. Hirsutism Round face Pitting edema Buffalo hump Hypoglycemia

Hirsutism Round face Buffalo hump

A nurse is caring for an infant who has just undergone myelomeningocele repair. What should the nursing plan of care include? Maintaining a supine position Monitoring for cerebrospinal fluid leakage Teaching clean catheterizations to parents Applying sterile moist dressings to the incision

Monitoring for cerebrospinal fluid leakage

A nurse in the pediatric clinic is assessing an 11-month-old infant with iron-deficiency anemia. The infant's hemoglobin is 8 g/dL (80 mmol/L). What does the nurse expect to observe when assessing the infant? Pallor Tremors Cyanosis Spasticity

Pallor

A nurse is evaluating a 3-year-old child's developmental progress. The inability to perform which task indicates to the nurse that there is a developmental delay? Copying a square Hopping on one foot Catching a ball reliably Using a spoon effectively

Using a spoon effectively Using a spoon effectively is a task expected of 3-year-old children. Copying a square is a task expected of 4- or 5-year-old children. Hopping on one foot and catching a ball reliably are tasks expected of 4-year-old children.

foundation of safe and effective nursing practice

clinical judgement

ability to think in systematic/logical manner with openness to question and reflect on the reasoning process

critical thinking

What does it mean for nurses to "know" their client's?

know cultural beliefs, spiritual beliefs, their patterns, ability to ambulate (walk), diet, demeanor, vital signs

A client who is receiving chemotherapy for lung cancer has nausea and vomiting because of the therapy. The client wants to know if it is true that smoking marijuana will help. What is the nurse's best response? "Smoking marijuana is not legal in any state." "Marijuana is effective for nausea and vomiting if it is injected." "Marijuana is not proven to be effective in preventing chemotherapy-induced nausea and vomiting." "There are some tetrahydrocannabinol (THC)-based medications that contain marijuana that control chemotherapy-induced nausea and vomiting in some people."

"There are some tetrahydrocannabinol (THC)-based medications that contain marijuana that control chemotherapy-induced nausea and vomiting in some people."

Describe REFLECTING in terms of it's position in the clinical judgement process

(evaluation) -the process of thinking and learning from experiences 2 types: reflection-in-action: happens in REAL TIME while care is occurring reflection-on-action: happens AFTER the patient care occurs -reflecting is critical for development of knowledge and improvement in reasoning

Describe RESPONDING in terms of it's position in the clinical judgement process

(planning/implementation) -implementation of actions and interventions based on patient needs -depending on the level of expertise, the nurse may or may not be able to judge the effectiveness of the intervention before initiating it

Describe NOTICING in terms of it's position in the clinical judgement process

-a nurse notices things abut a patient in the context of the nurse's background and experience, context of environment, and knowing the patient -nurses look for patterns that are consistent with previous experiences and use that info to guide care

What is Tanner's Research on clinical judgement?

-clinical judgements are more influenced by what the nurse brings to the situation than the situational objective data -clinical judgement rests on knowing the patient and his/her typical pattern of responses, and engagement with the patient and his/her concerns -clinical judgements are influence by the context in which the situation occurs and the culture of the nursing unit -nurses use various reasoning patterns alone or in combinations -reflection in practice is CRITICAL

Describe clinical judgement

-foundation of safe and effective nursing practice -interpretations and inferences that influence actions in clinical practice -essential skill that involves the interpretation of a client's needs, concerns, or health problems and the decision to take action or not, use or modify standard approaches or improvise new approaches on the basis of a client's response

How do you develop clinical judgement?

-knowledge and deep understanding -learning and recognizing patterns -apply concepts to nursing practice -skillful responding -reflective practice

Describe INTERPRETING in terms of it's position in the clinical judgement process

-the process of assembling info to make sense of it -types of reasoning patterns tend to vary with the experience of the nurse -novice nurses rely on analytic reasoning, while expert nurses draw from a variety of reasoning patterns (analytic, intuitive, and narrative)

Identify each part of the clinical judgement process within each example (Noticing, Interpreting, Responding, Reflection in and on action). After receiving report, a nurse enters her diabetic client's room to provide his breakfast tray and perform a morning physical assessment but finds the client is unresponsive and cool to the touch

1. What did you notice (Noticing) Unresponsive Cool to the touch Diabetic Hasn't eaten 2. What does it mean? (Interpreting) Unresponsive - BAD, unconscious Diabetic - ?? Last blood sugar Hypoglycemia 3. What will you do? (Responding) ABCs! (airway, breathing, circulation) Call for help Check blood sugar Check vitals 4. What is the potential effect of what you did? (Reflection in and on action) In action (during): Reflect while assessing Evaluate blood sugar reading On action (after): LOC (level of consciousness) improved? Retake blood sugar Skin temperature improved?

A client has symptoms associated with salmonellosis. Which data are most relevant for the nurse to obtain from the client's history? Any rectal cancer in the family All foods eaten in the past 24 hours Any recent extreme emotional stress An upper respiratory infection in the past 10 days

All foods eaten in the past 24 hours

Prednisone is prescribed for a client with an exacerbation of colitis. What does the nurse teach the client before administering the first dose? The client will be protected from getting an infection. Symptoms associated with the colitis will decrease slowly over time. Although the medication causes anorexia, weight loss may not occur. Although the medication decreases intestinal inflammation, it will not cure the colitis.

Although the medication decreases intestinal inflammation, it will not cure the colitis.

A client is scheduled for head and neck surgery. Although the healthcare provider has explained the surgery, the client still has moderate to severe anxiety. Which action should the nurse take initially? Attempt to discover what the client is concerned about. Elaborate on what the healthcare provider has already said. Teach the client to use the suction equipment preoperatively. Plan for postoperative communication because a tracheostomy is likely.

Attempt to discover what the client is concerned about.

A client has surgery for the creation of a colostomy. Postoperatively, what color does the nurse expect a viable stoma to be? Brick red Pale pink Light gray Dark purple

Brick red Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.

Which drug is contraindicated in clients with eating and seizure disorders? Bupropion Trazodone Amitriptyline Lithium citrate

Bupropion Bupropion is contraindicated in clients with eating and seizure disorders. Trazodone is contraindicated in clients with a known allergic reaction to this drug. Amitriptyline is contraindicated in clients who are pregnant and have known allergic reactions to this drug. Lithium citrate is contraindicated in clients with renal or cardiovascular disease.

A nurse is caring for several clients with major thought disorders such as schizophrenia. They are all being treated with neuroleptic drugs. How do these drugs act in the body to promote mental health? By inhibiting enzymes at the postsynaptic receptor site By decreasing serotonin at the postsynaptic receptor site By increasing dopamine uptake at the postsynaptic receptor site By blocking access to dopamine receptors at the postsynaptic receptor site

By blocking access to dopamine receptors at the postsynaptic receptor site Neuroleptics block access to dopamine receptors, rather than inhibiting enzymes, at postsynaptic sites. They increase, not decrease, serotonin at postsynaptic sites.

A 10-year-old child is admitted to the pediatric unit in vaso-occlusive sickle cell crisis. The nurse manager is planning to assign a room. Which child is the best roommate option for this client? Child with thalassemia Child with osteomyelitis Child with viral pneumonia Child with acute pharyngitis

Child with thalassemia Thalassemia is a hemolytic anemia that is not communicable; roommates with infectious diseases should be avoided because a child with sickle cell anemia is susceptible to infection. Osteomyelitis is an infection of the bone, pneumonia is an infection of the lung, and pharyngitis is an upper respiratory infection; therefore none of these children is a suitable roommate.

The primary healthcare provider prescribes two units of packed red blood cells for a client who is bleeding. Before blood administration, what is the nurse's priority? Obtaining the client's vital signs Letting the blood reach room temperature Monitoring the hemoglobin and hematocrit levels Determining proper typing and crossmatching of blood

Determining proper typing and crossmatching of blood Determining proper typing and crossmatching of blood is absolutely necessary to prevent an acute immunologic reaction if the donated blood is not compatible with the client's blood. Although important, obtaining the client's vital signs is not the highest priority. Blood must be kept cool until ready to use. If blood is at room temperature for 30 minutes before administration, it should be returned to the blood bank; after it is started, blood must be administered within 4 hours. Monitoring the hemoglobin and hematocrit levels is not the highest priority; these laboratory results were part of the data used to determine the need for the blood.

A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers? Avoiding leg massages Frequent repositioning of client Increasing fiber content in food Encouraging weight-bearing exercises

Frequent repositioning of client

A 4-year-old child is being prepared for a myringotomy in the ambulatory care unit. What is most important for the nurse to do when the child is called to the operating room? Removing the child's undergarments Placing the child's toys on the bedside table Allowing the child to climb onto the stretcher Having the parents accompany the child to the operating suite

Having the parents accompany the child to the operating suite

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? Loss of skin integrity caused by the burns Potential infection as a result of the burn injury Inadequate gas exchange caused by smoke inhalation Decreased fluid volume because of the depth of the burns

Inadequate gas exchange caused by smoke inhalation Maintaining a patent airway is the priority; because of the proximity of the chest and face to the nose and mouth, inhalation burns also may have occurred. Although loss of skin integrity caused by the burns is important, it is not the priority at this time. Although potential for infection as a result of the burn injury is important, it is not the priority. Although fluid needs are important, the gas exchange is priority.

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session? Elevated blood pressure Increased blood viscosity Fragility of the blood cells Immaturity of red blood cells

Increased blood viscosity

A 7-year-old child is admitted for surgery. What is the priority nursing action? Allowing a favorite toy to remain with the child Documenting the child's ASO titer and C-reactive protein level Inspecting the child's mouth for loose teeth and reporting the findings Encouraging a parent to stay until the child leaves for the operating room

Inspecting the child's mouth for loose teeth and reporting the findings School-aged children lose their primary teeth, which may be aspirated during surgery. Special precautions must be taken to maintain safety. Allowing a favorite toy to remain with the child is a comforting gesture, but it is not essential. There is no reason to obtain an antistreptolysin O (ASO) titer or a C-reactive protein level. Encouraging a parent to stay until the child leaves for the operating room is important but not always possible.

For which clinical indication should a nurse observe a child in whom autism is suspected? Lack of eye contact Crying for attention Catatonia-like rigidity Engaging in parallel play

Lack of eye contact Children with autism usually have a pervasive impairment of reciprocal social interaction. Lack of eye contact is a typical behavior associated with autism. Crying for attention, rigidity, and parallel play are not indicative of autism.

The nurse assesses a client for orthostatic hypotension. The results are: Lying heart rate = 70 beats/minute, BP = 110/70; Sitting heart rate = 78 beats/minute, BP = 106/66; Standing heart rate = 85 beats/minute, BP = 100/64. The nurse would expect which prescription from the primary healthcare provider? Increase furosemide from 20 mg by mouth (PO) to 40 mg PO daily Give 1 L of 0.9% normal saline (NS) bolus over 4 hours Start intravenous (IV) infusion of D5 ½ NS to run at 150 mL/hr No prescription change

No prescription change

is nursing care linear? what are the attributes of clinical judgement?

No, nurses must consider multiple complex variables -involves a holistic view (whole body, soul, mind) of patient situation -has a circular process orientation -requires reasoning and interpretation

what are the 4 steps of the clinical judgement process?

Noticing Interpreting Responding Reflection (reflection-in-action, reflection-on-action) Nursing, Intuition, Ridiculously, Right

A primigravida has just given birth. The nurse is aware that the client has type AB Rh-negative blood. Her newborn's blood type is B positive. What should the plan of care include? Determining the father's blood type Preparing for a maternal blood transfusion Observing the newborn for signs of ABO incompatibility Obtaining a prescription to administer Rho(D) immune globulin to the mother

Obtaining a prescription to administer Rho(D) immune globulin to the mother Rho(D) immune globulin will prevent sensitization resulting from Rh incompatibility that may arise between an Rh-negative mother and an Rh-positive newborn. Determining the father's blood type is unnecessary because only the mother's and infant's Rh factors are relevant. Preparing for a maternal blood transfusion is unnecessary; if a transfusion were needed, it would be for the newborn, not the mother. There is no ABO incompatibility; incompatibility might occur if the mother were O positive and the newborn had type A, B, or AB blood.

A client has paraplegia as a result of a motorcycle accident. What is the reason the nursing care plan should include turning the client every 1 to 2 hours? Maintain comfort Prevent pressure ulcers Prevent flexion contractures of the extremities Improve venous circulation in the lower extremities

Prevent pressure ulcers

A 4-month-old infant is admitted to the pediatric unit with severe tachypnea, flaring of the nares, wheezing, and irritability. The parents are told that the child has bronchiolitis and needs to be hospitalized for observation and treatment. While assessing the infant, the nurse determines that the infant is in respiratory failure. What clinical finding supports the nurse's conclusion? Wheezing cough Intercostal retractions Fine crackles on deep inspiration Sudden absence of breath sounds

Sudden absence of breath sounds A sudden absence of breath sounds occurs when bronchioles become obstructed and respiratory failure is imminent. A wheezing cough is a common manifestation of bronchiolitis and is caused by the passage of air through the narrowed airways; it does not herald respiratory failure. Intercostal retractions occur with mild and moderate respiratory distress in infants. Fine crackles are a routine occurrence with bronchiolitis, not a sign of respiratory failure.

A client with paralysis of the legs is found to have somatoform disorder, conversion type. What must the nurse consider when formulating a plan of care for this client? The illness is very real to the client and requires appropriate nursing care. Although the client believes that there is an illness, there is no cause for concern. There is no physiological basis for the illness; therefore only emotional care is needed. Nursing intervention is needed even though the nurse understands that the client is not ill.

The illness is very real to the client and requires appropriate nursing care. Individuals who have somatoform disorders are really ill; they need care in a nonthreatening environment. The client requires physiological and emotional care for treatment of motor or sensory functional deficits.

A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss? Measuring the abdominal girth daily Having the child urinate in a bedpan Testing the child's urine for proteinuria Weighing the child at the same time each day

Weighing the child at the same time each day

Identify each part of the clinical judgement process within each example (Noticing, Interpreting, Responding, Reflection in and on action). A nurse brings an elderly client with pneumonia his morning medications to take with his breakfast. As she begins to scan the meds ate the bedside the client begins coughing and becomes short of breath even while on 2 liters of oxygen per nasal cannula (RR 20, SpO2 89%).

What did you notice? (Noticing) Low O2, SOB, increase RR Choking? Elderly PNA 2L/NC O2 2. What does it mean? (Interpreting) Issues with eating? - problem with meds PNA - reason for low O2, also potential aspiration 3. What will you do? (Responding) O2 Increase HOB (head of bed) ABC's!! (airway specifically) NOT GIVE MEDS PO Take away food 4. What is the potential effect of what you did? (Reflection in and on action)

thinking process by which a nurse reaches a clinical judgement

clinical reasoning

Identify each part of the clinical judgement process within each example (Noticing, Interpreting, Responding, Reflection in and on action). A nurse receives an adult client in the Medical Surgical Unit from the post anesthesia care unit (PACU) after an abdominal exploratory laparotomy with colon resection. The PACU nurse reported the client complained of pain 10/10 postoperative and gave the client multiple intravenous narcotics. Once the client arrives in the unit her respiration rate (RR) is 8 and oxygen saturation (SpO2) is 90% on 2 liters per nasal cannula.

1. What did you notice? (Noticing) Not breathing well O2 saturation low Pain 10/10? Fresh post-op 2. What does it mean? (Interpreting) Medication induce low RR? 3. What will you do? (Responding) Reassess pain Increase O2 Assess the level of consciousness (LOC) Administer reversal med 4. What is the potential effect of what you did? (Reflection in and on action) Increase O2 levels (IN action) Reassess pain level (IN action) Reassess respiration and LOC

what are the critical thinking attitudes? describe each. (11)

1. confidence: learn to introduce yourself to a patient, speak with conviction; the ability to do things; decision-making; confidence in your procedures = confident patient 2. thinking independently: already knowing if O2 at 80 is low 3. fairness: not being biased 4. responsibility and authority: if you do something wrong be responsible and own it; responsibility for lack of knowledge (ask for help); if you don't have the authority to do something, don't do it 5. risk-taking: speaking up to someone; questioning a provider 6. discipline: act professional; time-management 7. perseverance: not taking the easy way out 8. creativity: think outside the box/adapt to meet patient's needs; pain management (PQRST); use music to calm people, reposition, coloring, guided imagery 9. curiosity: asking questions 10. integrity: doing the right thing when no one is looking; taking responsibility 11. humility: never thinking you are above anyone or any task (bed bath)

A client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. What should the nurse consider when formulating a response? Hypothyroidism is a gradual slowing of the body's function. A decrease in pituitary thyroid-stimulating hormone (TSH) will occur. Less thyroid tissue is available to supply thyroid hormone after surgery. Atrophy of tissue remaining after surgery reduces secretion of thyroid hormones.

Less thyroid tissue is available to supply thyroid hormone after surgery. After a thyroidectomy, thyroxine output usually is inadequate to maintain an appropriate metabolic rate. Hypothyroidism is decreased thyroid functioning, not a slowing of functions of the entire body. With hypothyroidism, the level of TSH from the pituitary usually is increased. Thyroid tissue remaining after surgery does not atrophy.

Client sustained a leg injury and is complaining of pain 8/10. describe the reflection in action vs. reflection on action

Reflection-IN-action: The nurse administers IV morphine as a response. While pushing the morphine over 3 minutes, the nurse asks if the pain is beginning to improve (since IV meds are fast acting but it has not all be administered yet) Reflection-ON-action: The nurse administers IV morphine as a response. After the medication has been given, the nurse goes back to the client's room 15 minutes later to reassess the client's pain level.

At 7:00 AM a nurse learns that an adolescent with diabetes had a 6:30 AM fasting blood glucose level of 180 mg/dL (10.0 mmol/L). What is the priority nursing action at this time? Encouraging the adolescent to start exercising Asking the adolescent to obtain an immediate glucometer reading Informing the adolescent that a complex carbohydrate such as cheese should be eaten Telling the adolescent that the prescribed dose of rapid-acting insulin should be administered

Telling the adolescent that the prescribed dose of rapid-acting insulin should be administered A blood glucose level of 180 mg/dL (10.0 mmol/L) is above the average range, and the prescribed rapid-acting insulin is needed. Although exercise does decrease insulin requirements and does lower the blood glucose level, the immediate action of insulin is needed. Asking the adolescent to obtain an immediate glucometer reading is an action that will not correct the problem; the blood glucose level is already known. Food intake at this time will increase the level of blood glucose.

The nurse manager working at a rehabilitation center for older adults notices an increase in the incidence of client falls. The nurse manager reprimands the nurses and staff responsible for the falls and places them on probation. Which statement best describes the nurse manger's leadership style? The nurse manager exhibits autocratic leadership. The nurse manager demonstrates shared leadership. The nurse manger exhibits good clinical leadership skills. The nurse manger demonstrates effective interprofessional leadership.

The nurse manager exhibits autocratic leadership. The nurse manager in this scenario exhibits autocratic leadership. In an autocratic leadership style, all decisions are solely made by the leader. Autocratic leaders are more concerned about the task and may use the threat of punishment to accomplish it. The nurse manager is not involved in direct client care and so is not demonstrating clinical leadership. The nurse manger is not involving the staff in the decision-making process and thus is not demonstrating shared leadership. The nurse manger is not involving members of the health care team across disciplines in the decision-making process and thus is not exhibiting interprofessional leadership.

interpretations and inferences that influence actions in clinical practice

clinical judgement