Critical Exam 2

The nurse is explaining how to develop an appropriate nursing diagnosis. Which participant statement indicates an appropriate understanding? "A nursing diagnosis is developed after the nurse evaluates the interventions provided." "A nursing diagnosis is based on clinical judgment that is derived from assessment data." "A nursing diagnosis is derived after the nurse develops the plan of care for the patient." "A nursing diagnosis is determined by the medical diagnosis and current patient needs."

"A nursing diagnosis is based on clinical judgment that is derived from assessment data." The nursing diagnosis is derived after collecting objective and subjective data from the patient and defining the patient problem. A nursing diagnosis is determined by using clinical judgment. The evaluation phase occurs after the interventions are provided. The nursing diagnosis is derived prior to developing the plan of care for the patient, not after. The nursing diagnosis is not necessarily based on the medical diagnosis. Nursing diagnoses may result from the complications that arise from medical problems.

A peer tells a new nurse that there is a standardized plan that can be used for a patient diagnosed with diabetes. The nurse asks the peer how standards of care can be helpful in developing a plan of care for this patient. Which response by the peer best answers this question? "The standards of care can be very helpful in these situations because they set benchmarks for nursing performance expectations." "Standards of care and standardized care plans refer to the same thing; they are very helpful in supporting the provision of evidence-based care." "A standardized plan is a set of common interventions that can be individualized for patients with the same diagnosis, which is different from standards of care." "Standards of care underlie the development of standardized plans; they are used to determine which nursing interventions should be included in the standardized plan."

"A standardized plan is a set of common interventions that can be individualized for patients with the same diagnosis, which is different from standards of care." A standardized plan specifies the nursing care for a group of patients with common needs, whereas standards of care set benchmarks for nursing performance expectations, including evidence of competent and effective clinical decision making that reflects professional behavior. Thus, stating that they are different would be the best response. Although the statement describing standards of care as benchmarks is accurate, it would not be very helpful when creating the plan of care for the patient (although it should always be kept in mind). Standards of care and standardized plans are not the same thing; thus, this is not an accurate statement. Standards of care do not underlie the development of standardized plans; standardized plan development is based on evidence. This is not an accurate statement. (NANDA-I ©2014)

The nurse is presenting how to differentiate between patient goals and outcomes. Which statement by the nurse is accurate? "Goals are established by the nurse and used to evaluate patient outcomes." "Goals include the subjective and objective data observed by the nurse." "Goals are patient responses, whereas outcomes are the patient's response to care." "Goals evaluate the patient's response to the plan of care developed by the nurse."

"Goals are patient responses, whereas outcomes are the patient's response to care." Goals are observable patient responses to the interventions provided by the nurse. Outcomes evaluate the patient's response to the plan of care. Goals should be mutually established between the nurse and the patient; they are not specifically set by the nurse and are not used to evaluate patient outcomes. Assessment involves subjective and objective data. Outcomes, not goals, evaluate the patient's response to the plan of care.

The nurse made a medication error while caring for a patient. Which statement by the nurse indicates that the nurse is interpreting the situation using guided reflection? "I was so busy giving medication that I misread the order and gave the wrong one to the wrong patient." "The medication didn't harm the patient, but I need to be more careful whenever I give medication." "I had to tell the patient and doctor that I gave the wrong medication. It was very embarrassing." "I should have remembered to check the patient's wristband even though I've been taking care of this patient for several days."

"I should have remembered to check the patient's wristband even though I've been taking care of this patient for several days." Stating that the nurse should have remembered to check the wristband is an example of interpreting the situation and what went wrong. The nurse is showing the process of observing after making the statement about being busy and misreading the order. Stating that it was embarrassing to make the mistake is an example of responding, and understanding the need to be more careful in the future is an example of reflecting.

The nurse admitting a patient asks the family if they would be available to help provide information to support the development of the nursing plan of care. The family asks the nurse what a nursing plan of care is. Which response by the nurse answers this question? "It will provide daily information about when the patient will be bathed, taken to the dining room for meals, and so forth." "The nursing plan of care helps to organize information about the patient's nursing care and ensures appropriate, individualized treatment." "A nursing plan of care helps us to organize and coordinate all of the provider's orders in one place for easy reference." "A nursing plan of care just refers to the daily medications and labs that the patient will be receiving."

"The nursing plan of care helps to organize information about the patient's nursing care and ensures appropriate, individualized treatment." A nursing plan of care organizes information about a patient's or family's care. It may include multiple nursing diagnoses (three to five are recommended), which helps the nurse to focus on nursing care that provides the best patient outcomes. It is not used to provide a daily schedule of times for bathing and eating. Although the nursing plan of care may be informed by the provider's orders, it is not a tool to organize all of the provider's orders in one place, nor is it used to list all medications or labs in one place.

The nurse educator is reviewing Tanner's clinical decision-making model and asks the students about the purpose of reflecting. Which response by a student is correct? To sense what is happening in a situation" "To learn from actions in order to make adjustments to future practice" "To gain understanding about a situation" "To analyze a situation to choose an action"

"To learn from actions in order to make adjustments to future practice" According to Tanner's model, reflecting helps the nurse learn from actions to make adjustments. Interpreting involves using logical reasoning to gain understanding about a situation and determine appropriate actions. Noticing requires a sense of what is happening in the patient situation. Responding is analyzing a situation to choose the best course of action.

The nurse is discussing​ Benner's skill acquisition model. Which statement should the nurse​ include? (Select all that​ apply.) A. ​"A competent nurse usually has 2dash3 years of​ experience." B. ​"New graduates are typically considered advanced​ beginners." C. ​"Proficient nurses can see the whole​ picture." D. ​"A novice acts by following​ rules." E. ​"An advanced beginner is intentional in planning​ care."

A B C D ​Rationale: According to​ Benner's model, a competent​ nurse, not an advanced​ beginner, is intentional in planning care. This statement would reflect the need for further teaching. All other statements are correct and reflect understanding of this model by the student nurse.

The nurse is explaining​ Tanner's clinical judgment model to a student nurse. Which element should the nurse explain is needed first to make a clinical​ judgment? A. Learning in nursing school B. Intuition C. Multiple years of experience D. Initiation of practice

A ​Rationale: According to​ Tanner's clinical judgment​ model, thinking like a nurse begins with nursing​ education, which teaches fundamental nursing skills and knowledge. Intuition develops from experience and nursing knowledge over time. Initiation of practice does improve critical thinking​ skills, but is not the initiating factor.

The nurse notes that a baby is not sitting independently and recommends that a developmental evaluation be performed. Which attribute of critical thinking is the nurse​ using? A. Salient cues B. Faulty reasoning C. Inductive reasoning D. Creativity

A ​Rationale: Salient cues are significant findings that direct a nurse to draw conclusions about a​ client's health status. The nurse has observed that the baby is not meeting developmental​ tasks, which directs the nurse to suggest further evaluation. The nurse is not using creativity or inductive​ reasoning, which is a​ bottom-up approach to client care. The nurse is not using faulty​ reasoning, which is an error in​ reasoning, in this situation.

The nurse is planning care for a new client with unstable blood glucose levels. Which should be the first action by the​ nurse? A. Complete an assessment on the client. B. Create a plan of nursing care for the client. C. Carry out solutions to manage the problem. D. Establish a specific nursing diagnosis.

A ​Rationale: The five steps of the nursing process are​ assessment, diagnosis, planning​ implementation, and evaluation. The nurse should first perform a thorough assessment and then create a nursing diagnosis based on the assessment data. The nurse should then create a plan of care with nursing interventions to address the​ diagnosis, follow the​ plan, and then evaluate the effectiveness of the nursing interventions.

The nurse has several clients who need care. Which type of decision does the nurse need to​ make? A. Priority decision B. Time management decision C. Value decision D. Scheduling decision

A ​Rationale: The nurse must prioritize which client to see first based on acuity and severity of the health problem. This is a priority decision. Scheduling and time management decisions involve scheduling client care or nursing activities to be most efficient with time. A value decision is required when there is a decision regarding nursing​ values, such as client confidentiality.

The nurse caring for a client who has a falling blood pressure is trying to decide what action to take next. Which is the first step in making the​ decision? A. Identify the problem and decision to be made. B. Put the identified option into action. C. Select the best option to try in the situation. D. List the different options and their risks and benefits.

A ​Rationale: When making a clinical​ decision, it is important for the nurse to first identify the problem or decision to be made.​ Next, the nurse should list the different options and identify the advantages and disadvantages to each. The nurse should then select the best option and put it into action.

The nurse is an advanced beginner within​ Benner's skill acquisition model of clinical judgment. Which characteristic describes the​ nurse? (Select all that​ apply.) A. Is a new graduate B. Is able to intentionally plan care C. Follows rules when acting D. Begins to recognize cues E. Can see the whole picture

A D ​Rationale: Characteristics of an advanced beginner nurse are being a new graduate and beginning to recognize significant cues from internal cognitive processing. A characteristic of a competent nurse is being able to intentionally plan care. A characteristic of a novice nurse is following rules when providing care. Being able to see the whole​ picture, when providing client care is characteristic of the proficient nurse.

The nurse works on a cardiopulmonary stepdown unit that uses standardized care plans for patients. In which patient scenario would a standardized plan of care be most appropriate? A patient 1 week post-stroke, tearful and depressed, is not participating actively in rehabilitation efforts and is refusing to eat. A patient 2 days post-stroke, with vital signs within normal limits, has begun the rehabilitation program. The family of a patient with chronic obstructive pulmonary disease (COPD) exacerbation indicates they are tired of dealing with the patient's issues because the patient refuses to quit smoking. A patient with recently diagnosed inoperable lung cancer has been homeless for the past 7 years.

A patient 2 days post-stroke, with vital signs within normal limits, has begun the rehabilitation program. Standardized care plans are used for predictable, commonly occurring problems for a specific diagnosis. In this case, a patient post-stroke who has begun the rehabilitation program would fit these criteria. Standardized care plans are not appropriate for patients with issues not common to all patients with a similar diagnosis, such as a post-stroke patient refusing to eat or participate in rehabilitation efforts, a COPD patient with family issues, and a patient with lung cancer who is homeless.

The nurse is providing care for a new patient admitted with heart failure (HF). The facility in which the nurse works has purchased a set of standardized plans for use. Which is a benefit of using a standardized plan for this patient versus generating an individual plan? A standardized plan uses evidence to account for all possibilities related to the diagnosis, eliminating the need for individualization. A standardized plan is more time efficient and includes a common set of interventions for a patient with HF. A standardized plan can be used to address both predictable and unpredictable problems that occur with HF, thus ensuring flexibility for many patient variations. A standardized plan is a multidisciplinary plan that becomes a part of the permanent patient record, thus making documentation easier.

A standardized plan is more time efficient and includes a common set of interventions for a patient with HF. The use of standardized plans is more time efficient than generating a single plan for patients with the same diagnosis. Standardized plans include a common set of interventions for the specified diagnosis. They do not account for all possibilities and should only be used for predictable, commonly occurring problems. An individual plan would need to be created to address unpredictable problems. A clinical pathway, not a standardized plan, is a multidisciplinary plan that becomes a part of the patient's permanent record.

The nurse is caring for a patient who is scheduled to have a chest x-ray at 9:00 a.m. and will be off the unit. The patient is also due to have medication at 9:00 a.m. Which action by the nurse is most appropriate? Administer the medication after the patient returns from x-ray. Administer the patient's medication at the start of shift. Administer the patient's medication at 8:45 a.m. Wait to administer the medication at the next dosage time.

Administer the patient's medication at 8:45 a.m

The nurse is providing care for a 3-year-old hospitalized child. As the nurse creates the nursing plan of care, the family informs the nurse that they usually give the toddler a warm bath every night before bed. How should the nurse best address this in the nursing plan of care? Teach the family the importance of helping the toddler adjust to hospital routines, including a morning bath. Instruct nursing assistive personnel to provide bath per unit guidelines every other day in the evening. Allow the family to provide a warm bath in the evening as allowed by the provider. Discuss current plan of care with the family and include the family in planning care as is feasible.

Allow the family to provide a warm bath in the evening as allowed by the provider. When possible, the plan should be customized to include patient preferences and choices. This helps to reinforce the patient's individuality and sense of control. Teaching the family that the toddler must adjust to the hospital routine and providing the bath per unit protocol does not address the family's preferences and choices for their toddler. Discussing the current plan of care and including the family is important but does not directly address the issue in this situation.

The nurse is caring for a 3-year-old and an 8-year-old patient who are sharing the same room. Which intervention is appropriate for the 8-year-old but not the toddler? Allowing the child to help the care provider whenever possible Providing age-appropriate explanations Giving options when appropriate Using play therapy and dolls and toys to explain treatments

Allowing the child to help the care provider whenever possible School-aged children benefit from hands-on exploration of equipment and materials and can help the care provider whenever possible, which can help to reduce anxiety. Both age groups can benefit from age-appropriate explanations and options when appropriate. Toddlers can use play therapy to better understand medical treatments, but this is not a good intervention for a school-aged child.

The nurse is considering opposing views before making a decision. Which attribute of critical thinking is the nurse​ exhibiting? A. Perseverance B. ​Fair-mindedness C. ​Open-mindedness D. Integrity

B ​Rationale: The critical thinking attribute that encourages being open to new ideas and ways of doing things is​ fair-mindedness. Open-mindedness refers to being open to different ideas or different methods to reach the same goal and is similar to independence. Challenging ideas and methods of carrying out nursing care explains integrity. Being motivated to find the best solution for quality client outcomes is perseverance.

The nurse is discussing the role of intellect in critical thinking. Which benefit should the nurse​ include? (Select all that​ apply.) A. Helps the nurse think outside the box B. Helps to clarify concepts C. Approaches situations objectively D. Assists with evaluating performance E. Differentiates fact from opinion

B C E ​Rationale: The critical thinking skill of intellect helps nurses differentiate facts from​ opinions, approach situations​ objectively, and clarify concepts. The critical thinking skill of creativity helps nurses think outside of the box. The critical thinking skill of inquiry helps nurses evaluate performance.

The nurse working in the intensive care unit (ICU) has decided to attend a professional critical care conference. Which critical thinking attitude is exemplified by the nurse's actions? Independence Awareness of self-limits Integrity Confidence

Awareness of self-limits The nurse is demonstrating awareness of self-limits by seeking new knowledge or skills. Nurses exhibit independence when they think on their own. Confidence is exemplified by self-assurance. Integrity is displayed when the nurse chooses the right option, even if it is not the popular option.

The nurse is providing care to a patient who recently had back surgery. Which nursing action is a collaborative nursing activity? Assisting the patient with bathing Adjusting the head of the patient's bed for comfort Arranging for physical therapy to ambulate the patient Assessing the patient's surgical wound site

Arranging for physical therapy to ambulate the patient Collaborative interventions encompass dependent interventions employed by the nurse under a physician's orders, under supervision, or according to specified routines and protocols, as well as actions the nurse carries out in collaboration with other healthcare team members, such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and cooperative relationships among, healthcare personnel and demonstrate the benefits of multidisciplinary patient care. The other choices are independent nursing activities, which are those activities that nurses can do within their scope of practice.

Which action by the nurse indicates support for a preschooler's decision-making ability? Soothing the child by rocking the child until calm Inviting the child to the interdisciplinary meeting Asking if the child would like to have the scheduled snack before or after going for an x-ray Showing the child the materials that will be used to stitch up the wound in the child's knee

Asking if the child would like to have the scheduled snack before or after going for an x-ray Preschoolers are able to make some decisions related to preference when information is provided to them in a way that makes sense to them. Asking preschoolers if they would like a scheduled snack before or after a procedure is an example of assisting a preschool child in decision making. Because adolescents are capable of participating in making decisions on their own behalf, it would be appropriate to invite an adolescent patient to come to an interdisciplinary meeting. School-age children benefit from direct explanations and would likely be interested in seeing and handling materials that will be used in their own care. Although infants cannot make decisions, they need to feel secure during care; soothing and rocking the infant patient is appropriate.

The nurse is creating a nursing plan of care for a patient admitted for surgery. Which headings should the nurse use as the pre- and postoperative nursing plan of care is created? List of medications, nursing diagnoses, goals/outcomes, nursing interventions, evaluation Demographic information, assessment data, nursing diagnoses, nursing interventions, outcomes Medical and nursing diagnoses, goals/outcomes, nursing interventions, evaluation Assessment, nursing diagnoses, goals/desired outcomes, nursing interventions, evaluation

Assessment, nursing diagnoses, goals/desired outcomes, nursing interventions, evaluation Headings for nursing care plans generally follow the nursing process phases and should include the following: "Assessment," "Nursing Diagnoses," "Goals/Desired Outcomes," "Nursing Interventions," and "Evaluation."

The nurse is formulating a plan of care for a pregnant patient. One goal set by the nurse is that the patient should attend all prenatal classes. Which step should the nurse take to motivate the patient to attain the goal? Tell the patient that it is in her best interest to attend classes. Associate the goal with a personal meaning for the patient. Inform the patient that insurance will not pay for the hospital stay for nonattendance at prenatal classes. Attend the classes with the patient to ensure compliance.

Associate the goal with a personal meaning for the patient. Goals are created from the patient's nursing diagnosis, specifically from the diagnostic label. Each nursing diagnosis has one goal. An appropriate goal statement to address the patient's insufficient knowledge about pregnancy is that the patient will attend prenatal classes. Therefore, the nurse should relate the classes to a personal meaning for the patient. Instructing the patient that it is in her best interest to attend or that insurance will not pay will not motivate the patient. The patient may see it as a threat. The nurse would not need to attend the classes.

The nurse is creating a legend for a concept map. At which point in the development of the concept map should this activity occur? At the beginning of the concept-map development At the end when the concept map is complete When the number of necessary data clusters has been determined After data clusters, nursing diagnoses, and nursing interventions have been created

At the beginning of the concept-map development The legend for the concept map is the first step in the process of developing a concept map. It is not done at the end; after determination of the number of data clusters needed; or once data clusters, nursing diagnoses, and nursing interventions have been created.

The nurse is caring for a patient with an electrolyte disturbance. The healthcare provider asks the nurse to draw an arterial blood gas (ABG), but the nurse has never performed the procedure and asks a more senior nurse to assist. Which critical thinking attitude is exemplified by the nurse's action? Approaching situations objectively Awareness of self-limits Perseverance Differentiating fact from fiction

Awareness of self-limits The nurse has demonstrated an awareness of self-limits and recognizes that the lack of experience in performing this procedure requires that the nurse asks for help. Differentiating fact from fiction and approaching situations objectively are aspects of intellect, not an attitude of critical thinking as used by the nurse in this scenario. The nurse is not demonstrating perseverance (the ability to stick with it) in this clinical situation.

The nurse decides to take vital signs and draw morning blood work before the patient's family comes to visit. Which type of decision does the nurse's action reflect? Priority decision Value decision Time-management decision Scheduling decision

Scheduling decision Nurses make four types of decisions. A scheduling decision is made when the nurse decides take vital signs and draw blood before visiting hours. Value decisions are those regarding patient confidentiality. Time-management decisions are those made to help the nurse manage time better. A priority decision is deciding what needs to be completed first and what can be delegated to a nursing assistant.

The nurse manager is looking at models of clinical judgment to use as an employee assessment tool. The nurse manager wishes to use a model that can evaluate clinical competence in the workplace. Which is best suited for the job? Tanner's clinical judgment model Benner's skill acquisition model Lasater's clinical judgment rubric Guided reflection

Benner's skill acquisition model Benner's skill acquisition model looks at clinical competence at five different levels and would be best suited for an employee evaluation tool. Tanner's clinical judgment model looks at the different cognitive skills needed in effective nursing practice. Lasater's clinical judgment rubric builds off Tanner's model to evaluate learners in a simulated environment. Guided reflection helps the nurse reflect on a given situation and is not suited as an employee evaluation tool.

When reprimanded for failing to label the date of changing a dressing the nurse​ states, "No one else on the unit does it​ either." Which type of faulty reasoning is the nurse​ demonstrating? A. Overgeneralization B. Circular reasoning C. Bandwagon D. ​Either-or fallacy

C ​Rationale: The nurse is using bandwagon faulty​ reasoning, which is doing something because everyone else is doing or not doing it. The​ either-or fallacy is the misbelief that a situation only has two solutions. Circular reasoning is the act of supporting an opinion by restating it using different words. Overgeneralization is the process of coming to a conclusion when there is not enough evidence to do so.

The nurse uses a clinical decision tree to determine the best course of action for a client who has signs and symptoms of a myocardial infarction. Which statement is true regarding this clinical decision​ tool? (Select all that​ apply.) A. It cannot be implemented by all nurses. B. It requires​ higher-level decision making. C. It can assist in decision making. D. It requires standardization of care. E. It requires no decision making.

C D ​Rationale: Clinical decision trees and protocols can assist in decision​ making, especially for nurses who do not have enough nursing experience or nursing knowledge to make decisions. This tool can assist in standardizing care because the tool can be used for all clients who present with similar symptoms. Because the tool has steps of decisions​ presented, it does not require​ higher-level decision making.​ However, the tool still requires some decision making by the nurse to ensure interventions are appropriate for the client.

A healthcare team on an orthopedic unit is discussing ways to reduce cost, increase efficiency, and improve patient outcomes while collaboratively providing care. Which approach to care would be most useful in guiding daily, multidisciplinary care for the patient population on this unit? Standardized care plan Column care plan Clinical pathway Concept map

Clinical pathway A clinical pathway is a standardized, evidence-based, multidisciplinary plan that outlines care for patients with common, predictable health problems; thus, the team would select this approach. A standardized care plan is specific to nursing interventions and would not necessarily be multidisciplinary in focus. Column care plans and concept maps are both ways to develop a care plan and would not be indicated for this use.

The nurse is preparing to discharge a patient after a hospital stay. Which task should the nurse perform to determine if goals have been met? Collect data to develop new nursing diagnoses for the home health nurse to follow. Collect data to provide discharge instructions to follow when at home. Collect data related to the goal and make decisions about nursing care effectiveness. Collect data related to patient-specific outcomes for accrediting bodies.

Collect data related to the goal and make decisions about nursing care effectiveness. Outcomes are evaluated to determine if the patient's goals have been met and for the effectiveness of the plan of care. Based on the evaluation, the plan of care is continued, modified, or terminated. The nurse will collect data at discharge to determine if the goals have been met and make decisions about nursing care effectiveness. If home health care is ordered at discharge, the home health nurse will develop a plan of care pertinent to self-care. The nurse provides discharge instructions based on healthcare provider orders, but this is not related to nursing diagnoses. The hospital will collect data for accrediting agencies, but this is not related to the nursing diagnoses and goal attainment.

Which process can be used to visualize relationships among clinical data and help to prioritize meeting patient needs? Column plan of care Standardized plan of care Concept map Clinical pathway

Concept map A concept map is a visual representation of a nursing plan of care in a patterned diagram with data and ideas; it helps to provide a visual guide for analyzing relationships among clinical data to help prioritize meeting patient needs. A column plan of care uses columns to categorize data for each phase of the nursing process, not a visual representation. A standardized plan of care specifies the nursing care for groups of patients with common needs, such as all patients with diabetes; this plan of care is not visually depicted. A clinical pathway is a standardized, evidence-based, multidisciplinary plan that outlines the expected care required for patients with common, predictable health conditions; it requires a physician's order and is not a visual depiction.

The nurse is struggling to see the "whole picture" when caring for a patient with very complex needs. Which method for developing the plan of care should the nurse consider? Column plan Standardized plan Concept map Clinical pathway

Concept map Concept maps can help the nurse to visualize and analyze relationships among clinical data, thus helping them view patient problems holistically. This would be the best development method for a nurse who is having difficulty seeing the "big picture." A column plan of care uses columns to categorize data for each phase of the nursing process, but it would not necessarily help a nurse better understand the "big picture." A standardized care plan specifies the nursing care for groups of patients with common needs, such as all patients with diabetes; this is not something which the nurse would develop. A clinical pathway is a standardized, evidence-based, multidisciplinary plan that outlines the expected care required for patients with common, predictable health conditions; it requires a physician's order and is not something the nurse would develop.

The nurse is sitting with the healthcare provider and a pregnant patient. The provider is explaining to the pregnant woman the various options for genetic testing that are currently available. The provider asks the patient which testing she would like to have done. The nurse understands that the provider is displaying which decision-making model? Maternalism Consumerism Paternalism Mutualism

Consumerism This is an example of the consumerism model, which is a hands-off approach to healthcare where the provider provides the scientific information and allows the patient to make the best decision. Mutualism is a process of shared decision making between both the patient and the provider. Paternalism is where the provider has the education and experience to make the best decision for the mom and baby. There is no maternalism model of decision making.

A healthcare team member accesses a patient's nursing plan of care because the nurse is currently unavailable. Which patient outcome is enhanced by this action? Continuity of care Adequate reimbursement for services provided Standardization of care Establishment of a clinical pathway

Continuity of care The ability of all healthcare team members to access the nursing plan of care enhances communication, resulting in continuity of care. Adequate reimbursement by insurance companies for services provided is a purpose of the nursing plan of care, but it is not a patient outcome that is enhanced by healthcare team members having access to the nursing plan of care. Standardization of care is achieved with a standardized care plan, but it is not a patient outcome that is enhanced by the ability of the healthcare team member to access the nursing plan of care. A clinical pathway is a standardized, evidence-based, multidisciplinary plan—it is not a patient outcome that is enhanced by the ability of healthcare team members to access nursing plans of care.

The nurse is caring for a toddler who appears frightened by the nurse. To make the child more at ease, the nurse gives the toddler a disposable tape measure to play with. Which critical thinking concept is the nurse displaying? Independence Confidence Creativity Concreteness

Creativity

The proficient nurse notices that an unconscious client has a heart rate of 42​ beats/min. Which action should the nurse​ perform? A. Review the​ client's medication list and look for potential side effects. B. Consult the policy and procedure book to determine at which heart rate to notify the code team. C. Document the findings and continue to monitor closely. D. Notify the rapid response team.

D ​Rationale: A proficient nurse would recognize the risk of impending cardiac arrest and the need to notify the rapid response team to restore normal cardiac functioning. Simply documenting the findings and waiting to act are not associated with proficiency. Reviewing the​ client's medication list for side effects or consulting the policy and procedure book for advice is an action usually performed by a novice or advanced beginner.

The nurse is caring for a pregnant client who wants a healthcare provider who will let her make all the decisions. Which​ decision-making model is the client looking​ for? A. Holistic B. Paternalistic C. Mutualistic D. Consumerist

D ​Rationale: Providers who follow a consumerist model of decision making tend to provide the important clinical​ information, but allow the client to make all of the decisions. Holistic and mutualistic providers focus on working together with the client to find a mutually agreeable solution. Paternalistic providers assume that their experience and education means that they will make the best decision for the client.

The nurse is using​ scenario-based simulations to teach the staff about clinical judgment. Which approach is the nurse​ using? A. ​Maslow's hierarchy of needs B. ​Benner's skill acquisition model C. ​Tanner's clinical judgment model D. ​Lasater's assessment rubric

D ​Rationale: The Lasater clinical judgment rubric is designed to allow for student reflection on the level of observed development of decision making and clinical judgment skills. This is exemplified with the use of simulation in a nursing lab.​ Tanner's clinical judgment model emphasizes the importance of elements the nurse uses in cognitive​ processing, including book​ knowledge, past​ experiences, and previous knowledge.​ Benner's skill acquisition model is based on the idea that the ability to make clinical judgments progresses as nurses gain experience and build their skills.​ Maslow's hierarchy of needs is a model nurses can use to inform how they prioritize care for a client.

The nurse assesses a client further to determine which ordered prn pain medication to administer. Which type of clinical decision making is the nurse​ using? A. Intuition B. Trial and error C. ​Problem-solving D. Choosing among alternatives

D ​Rationale: The nurse is choosing between two different alternatives for pain medication. The nurse is not using​ intuition, which is acting on a gut instinct about something. Trial and error is trying different​ options, which the nurse has not done. Problem solving is managing obstacles to maintain an orderly workday.

The nurse​ states, "Chronic obstructive pulmonary disease​ (COPD) is a chronic pulmonary disease and the nurse should place the client in high Fowler​ position." Which clinical reasoning concept is the nurse using in this​ statement? (Select all that​ apply.) A. Judgment B. Inquiry C. Inference D. Opinion E. Fact

D E Rationale: The nurse is using both fact and opinion in the statement. Facts can be confirmed by researchlong dash chronic obstructive pulmonary disease​ (COPD) is a chronic pulmonary disease. Opinions may be based on fact and are beliefs made over​ time, including nursing interventions such as placing the client with COPD in high Fowler position. Judgment is an evaluation of facts that reveal​ values; for​ example, place the client with COPD in high Fowler when the SpO2 is below a certain level. An inference is a conclusion that is drawn from​ facts, but goes beyond the established information. Inquiry is a form of research and does not apply here.

The nurse auditor is reviewing several patient charts to evaluate the effectiveness of the nursing care provided. Which information should the auditor look for that demonstrates nursing accountability and is essential for evaluation? Use of standardized nursing diagnoses Use of the phases of the nursing process as category headings Customization of the plan to include patient choices and preferences Date the plan was written and initiating nurse's signature

Date the plan was written and initiating nurse's signature The date the nursing plan of care was written is necessary for evaluation, review, and future planning. The nurse's signature indicates accountability for the plan. Use of standardized nursing diagnoses, phases of the nursing process as category headings, and customization of the plan to include patient choices/preferences do not indicate accountability for the plan.

The nurse is beginning a new shift and is reviewing the report given by the previous nurse. Which decision by the nurse is an example of a scheduling decision? Deciding what can be completed by a nursing assistant Deciding what information to share with other healthcare providers Deciding to bathe the patient before therapy Deciding when to change a dressing

Deciding to bathe the patient before therapy Nurses make four types of decisions. A scheduling decision is made when the nurse decides what a patient needs before attending a therapy session. A value decision occurs when deciding which information to share with other healthcare providers. A time-management decision is made when deciding when to change a dressing. A priority decision is deciding what can be assigned to a nursing assistant to complete.

The nurse is creating a concept map for a patient with multiple health problems. After creating clusters of assessment data, which should the nurse complete next to prioritize patient needs? Develop appropriate goals and outcomes for care; use lines to connect these to the relevant clusters. Develop priority nursing interventions; use lines to connect them to the relevant nursing diagnoses. Determine the priority nursing diagnosis for each cluster; use lines to connect them to the clusters. Determine goals and outcomes that can be achieved through nursing care; use lines to connect these to relevant nursing diagnoses.

Determine the priority nursing diagnosis for each cluster; use lines to connect them to the clusters. After creation of clusters of the subjective and objective assessment data, the nurse determines priority nursing diagnoses that are relative to each of the clusters. The nurse then draws connecting lines between the diagnoses and assessment data, which helps to prioritize patient needs. Interventions and goals and outcomes cannot be created until after nursing diagnoses are developed; thus, these would not be valid answers.

The nurse is creating a patient concept map for a simulation scenario. Which should the nurse do first when creating the concept map? Gather and sort significant clusters of assessment data. Develop a legend for the concept map. Look at the assessment data, including both subjective and objective data. Put a shape with patient information and priority medical diagnosis in the middle of the paper.

Develop a legend for the concept map. When creating a concept map, the nurse would first develop a legend by assigning shapes and colors for each nursing process phase and for the other categories of patient information. Gathering and sorting significant clusters of assessment data, looking at the assessment data (including both subjective and objective), and putting a shape with patient information and the priority medical diagnosis in the middle of the paper would follow development of the legend.

The nurse is planning to transfer a 76-year-old patient to a long-term care facility. The patient wants to live close to family; however, the facility that would best meet the patient's needs is a few miles farther away. Which action should the nurse implement? Tell the patient that being near family is not always a good idea. List other facilities so that the patient can make a better decision. Tell the patient that the facility that is closer to family is not accepting admissions. Discuss the advantages of the facility that is a bit farther away.

Discuss the advantages of the facility that is a bit farther away.

The nurse is using a clinical pathway to provide care to a patient hospitalized with pneumonia. While reviewing the clinical pathway, the nurse would note that the columns organize care in which manner? Each column represent a different health discipline. Each column represents a different nursing diagnosis. Each column represents a day of care. Each column represents an expected patient response.

Each column represents a day of care. A clinical pathway is usually organized with a column for each day, listing the interventions that should be carried out and the patient outcomes that should be achieved on that day. There are as many columns on the multidisciplinary care plan as the preset number of days allowed for the patient's diagnosis-related group (DRG). The columns do not represent different health disciplines, nursing diagnoses, or expected patient responses.

The nurse is caring for a patient with a nursing diagnosis of Ineffective Breathing Pattern related to diminished lung/chest wall expansion secondary to pneumonia. The current interventions of turning, coughing, deep breathing, and use of incentive spirometer have not improved the patient's breathing. Which independent nursing intervention should the nurse add to meet the patient's needs? Elevating the head of the bed to 45 degrees Administering nebulized bronchodilators Increasing the amount of oxygen provided Providing chest physiotherapy for secretions

Elevating the head of the bed to 45 degrees This patient has an ineffective breathing pattern related to diminished lung/chest wall expansion. Therefore, the nurse can include elevating the head of the bed in the plan of care. Administering nebulized bronchodilators, increasing oxygen, and chest physiotherapy all require an order from the healthcare provider. (NANDA-I © 2014)

A respiratory therapist is working with pediatric patients with cystic fibrosis. When the therapist asks the nurse about treatment guidelines for the patient, the nurse refers the therapist to a clinical pathway algorithm. Which describes the goal of this algorithm? Provide a visual depiction of the nursing care plan. Ensure standardization of care provided across clinical disciplines. Improve time efficiency when providing care for patients. Define interventions for which each discipline will be held accountable.

Ensure standardization of care provided across clinical disciplines. Clinical pathways developed as algorithms are designed to standardize care provided across clinical disciplines; thus, this best describes the goal of these pathways. They are also intended to improve the quality of care and outcomes. A concept map is a visual depiction of a nursing care plan, not a clinical pathway. Standardized care plans are used to increase time efficiency, not clinical pathway algorithms. Standards of care, not clinical pathway algorithms, define interventions for which different professionals are held accountable.

The nurse has developed a plan of care for a patient with a specific goal. The patient was unable to meet the goal by the stated time frame. Before revising the goal, which step must the nurse perform? Compare patient progress with that of other patients. Document noncompliance with the plan. Evaluate factors impeding goal attainment. Ask the healthcare provider for a more reasonable goal.

Evaluate factors impeding goal attainment. Occasionally, the plan of care may need to be revised if the goal is not met or is only partially met. Therefore, the nurse would revise the plan of care and extend the amount of time needed to meet the goal after evaluating factors that impede the patient from meeting the goal. The nurse would not compare one patient's progress against another, nor would the nurse document the patient being noncompliant. The nurse might discuss the patient's difficulty meeting the goal but base the new goal on the nursing assessment.

Which statement describes the evaluation phase of the nursing process? Evaluation is performed only after nursing interventions are performed Evaluation is performed throughout all phases of the nursing process. Evaluation focuses on determining changes and preventing complications. Evaluation is determined based on gathering subjective and objective data.

Evaluation is performed throughout all phases of the nursing process. Evaluation is performed throughout all phases of the nursing process. It is a constant, fluid process that is used to determine the effectiveness of planned interventions and includes reassessment of the patient. It is not only performed after nursing interventions. Implementation focuses on determining changes and preventing complications. Assessment is based on gathering subjective and objective data.

The nurse manager is preparing an annual performance appraisal for a staff nurse who has worked on a medical-surgical care area for 2 years. The manager determines that the staff nurse's level of proficiency is competent. Which action by the staff nurse prompts the manager to make this decision? Waited for direction from charge nurse before providing care Focused on a specific patient problem when planning care Determined how a new medication would impact a patient's other health problems Referred to the procedure manual to change the dressing at an intravenous (IV) site

Focused on a specific patient problem when planning care The competent practitioner focuses on a specific problem when planning patient care. The novice nurse has no experience and uses rules and needs direction when providing care. The novice nurse would refer to the procedure manual to change an IV dressing and wait for direction from the charge nurse before providing care. The proficient nurse can see the whole picture. The nurse who is proficient would determine how a new medication impacts a patient's other health problems.

The nurse is creating a concept map for a patient. Which guideline should be followed when preparing a concept map? Individualizing the care by using checklists and blank lines Highlighting medical treatments provided by other providers Including the rationales for each nursing intervention Following the sequence of the nursing process

Following the sequence of the nursing process One guideline to follow when creating a concept map is to follow the sequence of the nursing process. Individualizing the plan of care by using provided checklists and blank lines is a feature of a standardized care plan. A multidisciplinary clinical pathway includes medical treatments provided by other healthcare providers. Including the rationale for each nursing intervention is an expectation of nursing students when creating a column plan of care.

In which column in a plan of care should the nurse place this information: "Patient will walk 100 feet two times each shift"? Nursing interventions Evaluation Goals/desired outcomes Assessment

Goals/desired outcomes The statement "Patient will walk 100 feet twice per shift" is a goal/desired outcome; thus, it would be placed in that column. This statement is not an intervention or evaluation. This statement does not include assessment data. A column plan of care generally has four columns: nursing diagnosis, goals/desired outcomes, nursing interventions, and evaluation. Some agencies may also add an assessment column, whereas others may collapse it to three columns and combine the evaluation with the goals column. (NANDA-I ©2014)

The nurse determines the following nursing diagnosis for a patient: Impaired Urinary Elimination related to retention secondary to enlarged prostate. Which portion represents Axis 3 in the nursing diagnosis? Urinary Impaired Enlarged prostate Retention

Impaired Axis 3 consists of the modifier that gives meaning to the nursing diagnosis. In this diagnosis, the term Impaired represents Axis 3. Urinary represents Axis 1 because it is the focus of the nursing diagnosis. "Enlarged prostate" would be Axis 7 because it is the current or actual health problem. "Retention" is Axis 4 because it describes the focus of the problem. (NANDA-I © 2014)

A patient who is recovering from a motor vehicle crash has been ordered complete bedrest for 3 months. The patient presents with skin breakdown. Which nursing diagnosis statement is correct? Impaired Skin Integrity related to skin breakdown Impaired Skin Integrity related to motor vehicle crash Impaired Skin Integrity related to immobility Impaired Skin Integrity related to time in bed

Impaired Skin Integrity related to immobility The correct nursing diagnosis, Impaired Skin Integrity related to immobility, is a basic two-part statement that identifies the problem and the etiology. The motor vehicle is not the cause nor is the time in bed. Skin breakdown is the problem, so it would not be stated again in the diagnosis. (NANDA-I © 2014)

A facility has decided to use clinical pathways to guide multidisciplinary care for patients on the cardiac unit. This decision was made due to the multidisciplinary nature of clinical pathways. Which information included in the pathway best supports multidisciplinary use? Inclusion of clinical interventions and time frames for completion Inclusion of projected length of stay and daily sequence of care by providers Inclusion of medical treatments to be performed by different providers Inclusion of usual expectations of response and expected outcomes

Inclusion of medical treatments to be performed by different providers A clinical pathway is a standardized, evidence-based, multidisciplinary plan that outlines care for patients with common, predictable health problems. It is multidisciplinary because it includes medical treatments to be performed by different types of healthcare providers. Clinical interventions and time frames for completion, projected length of stay, daily sequence of care by providers, and usual expectations of response and expected outcomes are aspects of the clinical pathway but do not best indicate why the clinical pathway is considered multidisciplinary.

The nurse is working on the oncology floor of the hospital and notes that many of the patients request internet access so that they can communicate with loved ones more easily. Using this information, the nurse obtains a grant to purchase several laptops for the patients to share. Which type of reasoning did the nurse use to develop this protocol? Careful reasoning Clinical reasoning Deductive reasoning Inductive reasoning

Inductive reasoning Inductive reasoning uses a "bottom-up" approach that helps the nurse develop a theory or change in practice. In this example, the nurse observed a way to help some patients cope better with their diagnosis, then developed a protocol or practice to address their needs. The nurse may also be demonstrating clinical or careful reasoning, but these are not the best and most inclusive answers. Deductive reasoning uses a "top-down" approach and looks at a specific rule to see if examples apply to the rule.

The nurse is caring for a neonate who requires nasogastric (NG) tube feedings due to prematurity. The NG tube frequently slips out of position, and the nurse tries different approaches to prevent this from happening. Which critical thinking skill is the nurse demonstrating? Reflection Reasoning Inquiry Intellect

Inquiry When using inquiry, objective information is examined in order to clarify and find solutions to problems. Inquiry uses questions to find alternative approaches or solutions. Nurses use intellect to identify salient cues and group them into meaningful patterns. Clinical reasoning is the careful evaluation of information to improve patient care. Reflection is looking back at a situation to determine what worked, what did not work, or what could have been done better.

The nurse is caring for a newly admitted patient. Which skills should the nurse use to build rapport and trust with the patient? Cognitive Multidisciplinary Technical Interpersonal

Interpersonal Interpersonal skills are verbal and nonverbal skills used to communicate with patients, their families, and all members of the healthcare team. The effectiveness of a nursing action often depends largely on the nurse's ability to use therapeutic communication to build trust and rapport. Cognitive skills are the problem-solving skills implemented by nurses. Multidisciplinary collaboration includes discussing patient care with members of the healthcare team, but it is not a skill. Technical skills are the hands-on skills used by nurses to provide care.

The nurse forgets to provide the patient with discharge papers. When speaking with a coworker, the nurse states, "I should have remembered to bring the papers into the patient's room, but I got distracted with another task." Which guided reflection task is the nurse demonstrating? Observing Interpreting Responding Reflecting

Interpreting The nurse is interpreting the situation after thinking about the background information needed to understand the situation and making pertinent observations (observing) about what happened. Responding describes the nursing response to the situation. Reflecting describes an understanding of the "take-away" lesson from the experience or situation.

The nurse is caring for a patient who was admitted with abdominal pain. The patient's complete blood count (CBC) is normal, but the nurse is still concerned about the patient having a gastrointestinal bleed and monitors the patient closely. Which cognitive skill is the nurse displaying?

Intuition

The nurse with 15 years of obstetric experience is caring for a patient in labor who is reporting extreme pain. The nurse knows that the patient is likely getting very close to delivery but asks the provider to come and evaluate the patient. Which decision-making process is reflected in this situation? The scientific method The nursing process Trial and error Intuition

Intuition

The nurse is supervising an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP? Analyzing urine test results Evaluating color of urine Determining a patient's hydration status Measuring intake and output

Measuring intake and output Delegating patient care and assigning tasks are important responsibilities for registered nurses (RNs) because healthcare facilities use licensed practical nurses and many unlicensed assistive personnel (UAP). A UAP may perform tasks such as measuring intake and output, but the RN is still responsible for analyzing data, planning care, and evaluating outcomes. Analyzing test results, evaluating the color of a urine specimen, and determining a patient's hydration status all fall under assessment or evaluation.

The nurse is sitting with a laboring patient who is requesting intermittent fetal monitoring. The nurse is explaining the risks, benefits, and evidence to support the different types of monitoring. Which type of decision making is the nurse demonstrating? Consumerism Paternalism Mutualism Maternalism

Mutualism This is an example of mutualism, which is a process of shared decision making between both the patient and the provider. Paternalism is where the provider has the education and experience to make the best decision for the mom and baby. The consumerism model is a hands-off approach to healthcare where the provider provides the scientific information and allows the patient to make the best decision. There is no maternalism model of decision making.

The nurse auscultates a patient's breath sounds after the patient receives an albuterol nebulizer treatment secondary to wheezing. The nurse finds that the patient is still wheezing despite the therapy. Which aspect of Tanner's clinical judgment model is the nurse displaying? Interpreting Reflecting Responding Noticing

Noticing

The nurse is working for a facility that requires the use of a column framework for planning care. Information in which column of the plan of care is best derived from and supported by research evidence? Nursing diagnosis Goals/desired outcomes Nursing interventions Evaluation

Nursing interventions A column plan of care uses columns to categorize data for each phase of the nursing process. When writing nursing interventions, the nurse may be required to write a rationale for selecting a particular nursing intervention. This generally requires citing research-based evidence. Research evidence is not necessarily required to support nursing diagnosis, goals and outcomes, or evaluation, although evidence could be used for these sections as well.

The nurse educator is teaching student nurses about nursing judgment. Which statement by a student indicates effective learning? "Both clinical decision making and critical thinking are important parts of nursing judgment." "Students must be skilled at using clinical judgment while in nursing school." "Intuition is an important part of nursing judgment in the new nurse." "Both clinical decision making and critical thinking are important parts of nursing judgment." "Clinical decision making is scarcely used in nursing judgment."

Nursing judgment combines both critical thinking and clinical decision making when making decisions about patient care. Student nurses are not expected to have excellent clinical judgment because it is honed and improved over time. Clinical nursing judgment is frequently used by nurses. As new nurses become more experienced, they will increasingly be able to use their intuition to help in decision making.

The nurse is creating a column plan of care. Which information should the nurse place in the intervention column for a diabetic patient with a slow-healing foot wound? Patient will list three high-protein foods to include in the diet by the end of hospitalization. Patient named five foods high in protein prior to discharge. Obtain a dietary consult for the patient. Patient has a ½-inch by ½-inch open wound on the dorsal aspect of the right foot.

Obtain a dietary consult for the patient. Obtaining a dietary consult for the patient would be considered a nursing intervention and would be placed in that column. The statement that the patient will list three high-protein foods prior to discharge would be a goal/desired outcome, not an intervention. Stating that the patient named five high-protein foods prior to discharge indicates an evaluation (in this case the patient met the goal). The wound description would be assessment data and would go in the assessment column.

The nurse is caring for a patient with a history of diabetes mellitus. The nurse notices an upward trend to the patient's daily fasting serum blood glucose and notifies the patient's healthcare provider. Which level best describes this nurse according to Benner's skill acquisition model? Novice Advanced beginner Proficient Competent

PROFICIENT Rationale The nurse is proficient according to​ Benner's skill acquisition model. In this level of the​ model, the nurse develops her own rules for actions by analyzing significant cues and sees open double quote"the big picture.close double quote" The novice level includes those without any nursing experience who act only by​ rules, not cognition. The advanced beginner is typically a new graduate who begins to recognize significant cues using​ cognition, but is unable to piece all clinical cues into a whole picture. The competent​ nurse, according to​ Benner, has 2dash-3 years of nursing experience.​ However, the competent nurse is still unable to see the open double quote"big picture.close double quote Novice-beginners w/o nursing experience. follow rules. dependent. Advanced beginner- new grads. limited experience.recognize significant cues. Compentent- 2-3 yrs experience. intentional planning of care. not able see the bigger picture. Profient- see the whole picture. formulates own rules for action. Expert- many years of experience. intuitive practitioner. highly developed cognitve.

A pregnant patient presents with rising blood pressure and protein in her urine. After testing, the provider diagnoses the patient with preeclampsia and informs her that they are taking her to the operating room to deliver the baby through cesarean delivery immediately. Which decision-making model is displayed? Maternalism Mutualism Consumerism Paternalism

Paternalism

The nurse is examining the following nursing diagnosis statement: Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to diabetes. The use of "secondary to" in this diagnosis reflects which component? Pathophysiological disease process Primary identifiable nursing problem Axis 2 of the nursing diagnosis Subjective data obtained

Pathophysiological disease process In this instance, the secondary clause reflects the pathophysiological disease process that caused the problem. The nursing diagnosis is the primary nursing problem. Axis 2 represents the patient or subject of the diagnosis. Subjective data lead the nurse to develop the nursing diagnosis. (NANDA-I © 2014)

The nurse is completing the admission process for a patient scheduled for a radical prostatectomy. Which should the nurse provide to the patient to help him best understand what to expect in terms of time frames, actions, and results related to this procedure? Concept map Clinical pathway Patient education pamphlet Patient-specific clinical pathway

Patient-specific clinical pathway Patient-specific clinical pathways help patients understand what to expect in terms of time frames, actions, and results as related to diagnosis-related groups (DRGs). Concept maps are a visual depiction of a nursing care plan and would not provide this information. Clinical pathways are standardized, multidisciplinary care plans that outline expected care required for patients with common, predictable problems; they are intended for use by the healthcare team, not to provide information to patients. Patient education pamphlets can generally provide some of this information but are not generally specific in relation to time frames and actions; thus, they would not be the best at providing this information.

The nurse is looking at ways to help infants in the healthcare process. Which intervention is appropriate for this age group? Place cots for parents to stay over in all patient rooms. Allow for hands-on exploration of all equipment. Encourage the use of play therapy and toys in the treatment rooms. Provide simple options when appropriate.

Place cots for parents to stay over in all patient rooms.

The nurse is developing a plan of care for a patient admitted to the hospital for pneumonia. Which phase of the nursing process will the nurse use to develop interventions? Assessment Planning Implementation Nursing diagnosis

Planning Nursing interventions are selected and written during the planning phase of the nursing process. The nursing process begins with assessment, which involves the collection, organization, and validation of data. These data are used to formulate a nursing diagnosis. During the implementation phase, interventions are prioritized and carried out.

The nursing team is reviewing the possible use of clinical pathways to guide care for patients on the pulmonary care unit. One of the team members asks how the number of columns is determined for the clinical pathway. Which response by the team facilitator provides the best explanation? Each insurer determines the number of days it will cover for a patient related to the specific diagnosis, which determines the number of columns. The number of columns is preset regardless of diagnosis and includes assessment, pretreatment, and treatment of the specified diagnosis. Preset diagnosis-related groups (DRGs) determine the number of days allowed for this diagnosis and thus the number of columns. Column numbers vary by each patient's diagnosis, patient age, and existence of comorbidities; thus, the number of columns can vary widely between patients.

Preset diagnosis-related groups (DRGs) determine the number of days allowed for this diagnosis and thus the number of columns. Preset diagnosis-related groups (DRGs) determine the number of days allowed for a specific diagnosis. Each column represents a day; thus, this would be the best response to this question. Insurers generally also use the DRG preset number of days; thus, this would not be the best response. Information about assessment, pretreatment, and treatment of the specified diagnosis may be included in the clinical pathway but does not determine the number of columns. Clinical pathways do not vary by patient.

The nurse is creating a plan of care for a patient with complex health problems, including sepsis. Which action should the nurse take to focus nursing care and support the best patient outcomes? Create two to three general categories of nursing diagnosis. Focus nursing diagnoses only on those issues caused by the sepsis. Prioritize three to five nursing diagnoses. List all applicable nursing diagnoses, highlighting those that have highest priority.

Prioritize three to five nursing diagnoses. When creating a nursing care plan, it is important to list only three to five nursing diagnoses to help the nurse focus on nursing care that provides the best outcomes. It would not be appropriate to create general categories of nursing diagnosis, to focus only on those related to the sepsis, or to list all applicable nursing diagnoses because this may lead to difficulties in focusing nursing care, ultimately affecting patient outcomes.

The nurse is implementing care for patients in an acute care facility and asks a patient about dietary restrictions related to religion or ethnicity. Which nursing goal is the nurse meeting with this question? Follow prescribed dietary needs. Determine need for special services. Provide culturally competent care. Promote contentment in the patient.

Provide culturally competent care. The nurse should ask about dietary preferences related to religion and ethnicity to provide culturally competent care. The nurse would discuss dietary needs that relate to disease processes with the healthcare provider. The nurse would communicate the needs for special services through the healthcare provider. The nurse would ask the patient about food preferences to promote contentment in the patient.

The nurse is developing a plan of care for a patient with the nursing diagnosis Impaired Physical Mobility related to inactivity secondary to arthritis. The nurse and patient develop a goal of ambulating the hall three times a day with a wheeled walker. Which purpose should this goal help achieve? Measure the end result of nursing action. Identify a time frame for an action to occur. Provide direction for nursing interventions. Evaluate the patient's response to the plan of care.

Provide direction for nursing interventions. Goals provide direction when selecting nursing interventions. Therefore, the nurse and patient develop the goal of ambulating the hallways three times a day to help provide guidance for improving mobility. Outcomes are used to evaluate the patient's response to the plan of care and to measure the end result of the nursing action. Identifying a time frame for an action to occur is part of the goal statement; however, it is not the purpose of a goal. (NANDA-I © 2014)

The nurse determines that the patient has not met the plan of care for the nursing diagnosis Skin Integrity, Impaired because the wound has not healed within the time frame specified. The nurse chooses to revise the plan of care. Which step should the nurse perform first? Talk to the healthcare provider. Set a new, reachable goal. Reassess the wound. Change the interventions.

Reassess the wound. The nurse should always reassess the patient prior to changing the plan of care. This determines future needs. The nurse would not need to discuss this with the healthcare provider because these are nursing interventions. The nurse may need to change interventions or set new goals, but these are not the first steps. (NANDA-I ©2014)

A new nurse is speaking with a mentor about a mistake made the day before. The mentor encourages the nurse to review the situation and make a mental note to respond differently the next time the situation occurs. Which process is the mentor encouraging? Responding Noticing Reflecting Interpreting

Reflecting According to Tanner's clinical judgment model, this is an example of reflecting because the nurse is reviewing the previous clinical actions. Noticing is the recognition of the presence or absence of expected significant cues from the patient's response to an illness or medical condition. Interpreting involves using logical reasoning to determine appropriate action after noticing a clinical finding. Responding occurs when the nurse acts based on what is found and interpreted.

The nurse is caring for a young woman who is receiving antibiotics for a urinary tract infection. The patient returns to the clinic complaining of continued burning urination 4 days after starting the medication. The nurse looks at the patient's chart and notices that a urine culture was never performed. Which feature of Tanner's clinical judgment model is displayed here? Interpreting Noticing Reflecting Responding

Reflecting According to Tanner's clinical judgment model, this is an example of reflecting because the nurse is reviewing the previous clinical actions. Noticing is the recognition of the presence or absence of expected significant cues from the patient's response to an illness or medical condition. Interpreting involves using logical reasoning to determine appropriate action after noticing a clinical finding. Responding occurs when the nurse acts based on what is found and interpreted.

The nurse is reviewing assessment data collected from a patient with pneumonia. Which data should the nurse identify as subjective? Presence of cough Observation of yellow sputum Rapid breathing Report of difficulty breathing

Report of difficulty breathing Subjective data are those that the patient feels, such as difficulty breathing. Objective data are those that the nurse can observe, measure, feel, hear, or smell.

The nurse is evaluating the current plan of care for a patient who is receiving care in a long-term healthcare facility. The evaluation indicates that the patient is not meeting goals related to mobility. Which is an appropriate nursing action at this time? Concluding that the problem is resolved Determining that the patient does not have any risk factors Asking the patient to try harder Revising the plan of care

Revising the plan of care The patient is not meeting goals related to mobility, so the plan of care must be revised. The nurse will work with the patient to determine how the plan might be revised. Perhaps assessment data were not fully considered, or goals were not within reasonable expectations for what the patient is able to accomplish. Concluding that the problem is resolved would be inaccurate. The nurse would be wise to reassess risk factors as part of reassessment before revising the plan of care. Asking the patient to try harder is not appropriate.

The nurse identifies the diagnosis Imbalanced Nutrition: Less than Body Requirements related to poor nutrition, as evidenced by low serum albumin level, for a 65-year-old patient with osteoporosis. Which format should the nurse use to write goals for this patient? SBAR PIE SMART CBE

SMART SMART charting is used to write a goal statement and stands for specific single action, measurable, attainable, relevant, and time-limited. SBAR, PIE, and CBE are all forms of charting, not goal setting. SBAR stands for situation, background, assessment, and recommendations. PIE stands for problem, intervention, and evaluation. CBE stands for charting by exception and is used to document only abnormal findings. (NANDA-I © 2014)

The nurse is caring for a patient who has difficulty breathing. Which nursing action would be considered independent? Administering medication to relax breathing Prescribing oxygen therapy Sitting the patient up in bed Ordering chest physiotherapy

Sitting the patient up in bed Independent interventions are those activities that nurses are licensed to do within their scope of practice—in other words, areas of healthcare that are unique to nursing and separate and distinct from medical management. A nurse can independently make the decision to sit the patient up in bed to help with breathing. Collaborative interventions encompass dependent interventions employed by the nurse under a physician's orders, under supervision, or according to specified routines. Collaborative nursing activities reflect the overlapping responsibilities of, and cooperative relationships among, healthcare personnel and demonstrate the benefits of multidisciplinary patient care. Healthcare providers would prescribe medications, oxygen therapies, and specific therapies. The nurse would be responsible for implementing this care.

The nurse has just admitted a 72-year-old patient for total hip replacement to a unit that utilizes clinical pathways. The patient is otherwise healthy, and recovery is expected to progress normally. How will the clinical pathway for this patient be initiated? The physical therapist will initiate the clinical pathway for this patient if appropriate. The nurse will initiate the clinical pathway after verification of appropriateness by the nursing supervisor. The healthcare provider will write an order for the appropriate clinical pathway for this patient. The nurse will complete a patient assessment to determine if the patient meets the parameters for the clinical pathway, then initiate it.

The healthcare provider will write an order for the appropriate clinical pathway for this patient. Clinical pathways are initiated by healthcare provider order. They are not initiated by the physical therapist or the nurse independently.

Which clinical situation best exemplifies the nurse who is choosing between alternatives when making a clinical decision? The nurse has a "gut reaction" to the patient's pain and calls the patient's physician. The nurse changes the patient's position numerous times until the patient appears in less pain. The nurse administers an intravenous (IV) narcotic instead of an oral narcotic. The nurse determines that the patient's nursing diagnosis is Pain, Acute.

The nurse administers an intravenous (IV) narcotic instead of an oral narcotic. The nurse who administers an IV narcotic instead of an oral narcotic is choosing between alternatives. The nurse who helps the patient change position numerous times is using trial and error. The nurse acting on a "gut reaction" is using intuition. The nurse determining the nursing diagnosis is utilizing the nursing process. (NANDA-I ©2014)

The nurse is caring for a teenager who requires surgery to repair a broken femur after a motor vehicle crash. Which statement about patient consent is correct? The parents must provide consent, and the teen must sign an assent form. The teenager must sign the consent form. The teenager must sign the consent form, and the parents must also provide assent. The parents must provide consent.

The parents must provide consent.

A patient is admitted to the hospital with pneumonia. The nurse develops a plan of care with a nursing diagnosis of Impaired Gas Exchange related to inadequate ventilation secondary to atelectasis. Which goal includes all elements of a goal statement? The patient will be given supplemental oxygen to use via nasal cannula. The patient will demonstrate correct use of the incentive spirometer after the teaching session. The patient will be given bronchodilators as prescribed. The patient will be instructed in use of the incentive spirometer every hour.

The patient will demonstrate correct use of the incentive spirometer after the teaching session. An appropriate goal for a patient with any nursing diagnosis includes a subject and verb and is both measurable and patient centered. The statement of the patient demonstrating the correct use of incentive spirometry after a teaching session meets these requirements. It is also realistic and relevant. Providing supplemental oxygen, administering bronchodilators, and instructing on the incentive spirometer are all nursing interventions, not goals. (NANDA-I © 2014)

The nurse is caring for a patient with malnutrition and identifies a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements related to poor oral intake secondary to cancer treatment. Which goal set by the nurse is an example of a specific and measurable goal? The patient will verbalize foods that are needed to gain weight. The patient will experience no further nausea and vomiting. The patient will gain weight over the next few months. The patient will take in 80 grams of protein per day.

The patient will take in 80 grams of protein per day. The goal of consuming 80 mg of protein per day is a specific, measurable goal with a time frame. It is also relevant and attainable. Verbalizing foods needed to gain weight, experiencing no further nausea and vomiting, and gaining weight over the next few months are not specific nor are they measurable. (NANDA-I © 2014)

Which short-term goal should the nurse view as appropriate for a patient with the nursing diagnosis Deficient Knowledge related to disease process secondary to diabetes? The patient will follow a diabetic diet with 90% compliance within 3 months. The patient will verbalize understanding of how insulin affects blood sugar by the end of the day. The patient will maintain blood sugars between 80 and 120 mg/dL within 1 month. The patient will identify ways to prevent complications from diabetes within 2 months.

The patient will verbalize understanding of how insulin affects blood sugar by the end of the day. Goal statements include a time frame for completion. Short-term goals are useful for patients needing a limited amount of nursing care. These goals can be achieved in a few hours to a few days. Therefore, the goal of understanding how insulin affects blood sugar by the end of the day is an example of a short-term goal. The other goals have time frames of 1 month or longer, making them long-term goals. (NANDA-I © 2014)

The nurse is caring for a patient who is 8 weeks pregnant, reports never having been pregnant before, and does not know what to expect. The nurse instructs the patient to keep all scheduled prenatal clinical visits and states, "These classes will help you and your baby to stay healthy." Which is the reason for the nurse to make this statement? To educate the patient on the importance of attending the classes To develop a nursing diagnosis of Knowledge, Deficient for the patient To motivate the patient by associating a personal meaning with the goal To provide the patient a list of reasons why attending classes is important.

To motivate the patient by associating a personal meaning with the goal The patient reports a knowledge deficit by stating that she does not know what to expect. Therefore, the nurse should encourage the patient to attend prenatal classes to learn what is expected and relate it to a personal goal. Educating the patient is important, but relating the goal to something with personal meaning would improve motivation. The nursing diagnosis set by the nurse does not help the patient understand why attendance at prenatal classes is important. Providing the patient a list of pros for attending will not be as successful as the patient relating the classes to something meaningful. (NANDA-I ©2014)

The nurse is caring for a patient who is having back discomfort. The nurse helps the patient change position several times until comfortable. Which process is defined by this action? Intuition Trial and error The nursing process Clinical decision making

Trial and error Trial and error is the process of trying different options to see what works and what does not, such as trying different positions to find one that is comfortable for the patient. Intuition is relying on subconscious clues and previous experience to find patterns in patient behavior. The nursing process uses five defined steps (assessment, diagnosis, planning, implementation, and evaluation) to solve a problem. Clinical decision making uses the nurse's skills, experience, and knowledge to make a decision.

A patient reports hematuria along with the pain. After reviewing the patient's chart and assessing the patient, the nurse documented the following nursing diagnosis: Acute Pain related to urinary obstruction secondary to prostate cancer. Which part of the nursing diagnosis statement reflects the etiology? Hematuria Acute Pain Urinary obstruction Prostate cancer

Urinary obstruction The etiology of the nursing diagnosis statement is the urinary obstruction because this is leading to the acute pain due to bladder enlargement. The nursing diagnosis is Acute Pain. "Hematuria" is the assessment data. The medical diagnosis is prostate cancer. (NANDA-I © 2014)

The nurse is creating a concept map to guide a plan of care for a patient with multiple health problems. The nurse is using paper and pencil to create the map because the nurse is not comfortable with using the computer for this activity. How could the nurse easily improve the readability of the map? Find a software program that the nurse is comfortable with. Use a concept-map template. Make sure to match colors and shapes and coordinate patterns. Use colored pencils or markers.

Use colored pencils or markers. There are a variety of methods and tools that can be used to create concept maps. Using just pencil and paper can make it difficult to understand the visual depiction of the plan of care. In this situation, because the nurse is not comfortable using a computer, use of different colored pencils is appropriate to help to delineate specific areas of the map. Expecting a nurse who has indicated difficulty using electronic software to do so would not be expected or necessary. Using a concept-map template would not necessarily be the best way to improve the nurse's preferred method of developing a concept map. Spending a great deal of time matching colors and shapes and coordinating patterns is not a good use of time and does not necessarily enhance the process.

The nurse is planning interventions for a patient with a nursing diagnosis of Activity Intolerance related to weakness, as evidenced by inability to walk two steps. Which part of the nursing diagnosis statement is used as the framework for planning nursing interventions? Weakness Previous health history Activity Intolerance Inability to walk two steps

Weakness The framework for selecting nursing interventions is created when the correct problem is identified during the assessment and nursing diagnosis phases. In this instance, it is the weakness. The diagnostic label, Activity Intolerance, may have several etiologies, such as pain or sedentary lifestyle, so it is important to define the cause of the problem so that interventions are appropriate. A patient's previous health history is not used as the framework for identifying nursing interventions. A sign of not being able to walk two steps helps explain how a problem is affecting a patient. (NANDA-I © 2014)

The school nurse is looking at the effects that increasing recess and recreation time has in the classroom. The nurse plans to assign some classes within the school an additional hour of recess each day, and the remaining classes will stay on the current schedule. Which concept of problem solving and critical thinking should be most useful in this situation? Intuition Trial and error The nursing process The scientific method

the scientific method