Exam 2

factors that effect priority

-Client's health values and beliefs -Client's priorities -Resources available to nurse and client -Urgency of the health problem -Medical treatment plan

Priorities

-High priority (life-threatening) -Medium priority (health-threatening) -Low priority (developmental needs)

Standardized care plans

-Kept with client's individualized care plan, then permanent medical record -Provide detailed interventions -Written in the nursing process format

Quality Assurance

-Three components: ▪Structure evaluation -Focuses on setting ▪Process evaluation -Focuses on care given ▪Outcome evaluation -Focuses on demonstrable changes in client's health status as result of nursing care

A cue is considered significant if

-points to a negative or positive change in a client's health status or pattern -varies from norm of the client population -indicates a developmental delay

A client reports feeling hungry, but does not eat when food is served. Using clinical reasoning skills, the nurse should perform which of the following? 1. Assess why the client is not ingesting the food provided 2. Continue to leave the food at the client's bedside until the client is hungry enough to eat 3. Notify the primary care provider that tube feeding may be indicated soon 4. Believe the client is not really hungry

1. Assess why the client is not ingesting the food provided

analyzing steps

1. compare data against standards 2. cluster the cues- det. any patterns in the data 3. identify gaps and inconsistencies

when a nurse considers that a client is from a developing country and may have a positive tuberculosis test due to a prior vaccination, which critical thinking attitude and skills the nurse practicing? 1. Creating environments to support critical thinking 2. tolerating dissonance and ambiguity 3. self assessment 4. seeking situations where good thinking is practical

1. creating environments to support critical thinking

purposes of daily planning

1. determine whether or not the client's health status has changed 2. to set priorities for the client's care during the shift 3. to decide which problems to focus on during the shift 4. to coordinate the nurse's activities so that more than one problem can be addressed at each client contact

process of implementing

1. reassess the client 2. determining the nurse's need for assistance 3. implementing the nursing interventions 4. supervising delegated care 5. documenting nursing activities

4 circles of critical thinking

1. technological skills and competencies 2. CT characteristics 3. theoretical and experimental knowledge 4. interpersonal and self management skills

Components of Nursing Diagnosis

1. the problem and its definition (Diagnostic Label) 2. the etiology 3. the defining characteristics

The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring other positions. What decision making is the nurse engaging in? 1. The research method 2. the trial and error method 3. intuition 4. the nursing process

1. the research method

a client in a cardiac rehabilitation program says to the nurse, "I have to eat a low sodium diet for the rest of my life, and I hate it!" which of the following is the most appropriate response by the nurse? 1. "I will get a dietary consult to talk to you before next week" 2. "what do you think is so difficult about following a low sodium diet?" 3. "at least you survived a heart attack and are able to return to work" 4. "you may not need to follow a low sodium diet for as long as you think"

2 "what do you think is so difficult about following a low sodium diet?"

A client complains of shortness of breath. During assessment the nurse observes that the client has of the left leg only. The nurse reviews evidence-based practice literature and reflects on a previous client with the same clinical manifestation. What do these actions represent? 1. clinical judgement 2. clinical reasoning 3. reflection 4. intuition

2. Clinical reasoning

The nurse is concerned about a client who begins to breathe very rapidly. Which action by the nurse reflects clinical reasoning? 1. Notify the primary care provider. 2. Obtain vital signs and oxygen saturation. 3. Request a chest X-ray 4. Call the rapid response team.

2. obtain vitals and oxygen saturation

In the clinical reasoning process, the nurse sets and weighs the criteria, examines alternatives, and performs which of the following before implementing a plan? 1. Reexamines the purpose for making the decision. 2. Consult the client and family members to determine their view of the criteria. 3. Identifies and considers various means for reaching the outcomes. 4. Determines the logical course of action should intervening problems arise.

4. Determine the logical source of action should intervening problems arise

The nurse is teaching a client about wound care during a follow up visit and clients home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidence based practices when the client states, "I just don't know how I can afford these dressings"? 1. Integrity 2. intellectual humility 3. confidence 4. independence

4. integrity

which reasoning process describes the nurses actions when the nurse evaluates possible solutions for care of an infected wound for optimal client outcome? 1. Intuition 2. research process 3. trial and error 4. problem solving

4. problem solving

A nurse is caring for a client who is 24 hours postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "I will call the surgeon an ask for a change in diet." the surgeon hears the nurses report and prescribes a full liquid diet. The nurse used which of the following basic levels of critical thinking? A. basic B. commitment C. complex D. integrity

A. Basic

a charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the clients MAR and noted the last dose of pain medication was six hours ago. The prescription reads every four hours PRN for pain. The nurse administered the medication and checked with the client 40 minutes later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? a. Assessment b. Planning c. Intervention d. Evaluation

A. assessment

a newly licensed nurse is considering strategies to improve critical thinking. Which of the following action should a nurse take? (select all that apply) a. Find a mentor b. use a journal to write about outcomes of clinical judgments c. review articles about evidence based practice d. limit consultations with other professionals involved in a client's care e. make quick decisions when unsure about a client's needs

A. find a mentor B. use a journal to write about outcomes of clinical judgements C. review articles about evidence based practice

a nurse is caring for a client who has a new prescription for anti hypertensive medication period prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. Knowledge B. experience C. intuition D. Competence

A. knowledge

By the second postoperative day, client is not achieve satisfactory pain relief period based on evaluations which of the following actions should the nurse take, according to the nursing process? a. Re assess the client to determine the reasons for inadequate pain relief b. wait to see whether the pain lessens during the next 24 hours c. change the plan of care to provide different pain relief interventions d. teach the client about the plan of care for managing the pain

A. reassess the client to determine the reasons for inadequate pain relief

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply) a. Respiratory rate is 22/min with even unlabored respirations. b. The clients partner states, "they said they hurt after walking about 10 minutes." c. the client's pain rating is a 3 on a scale of zero to 10 d. the client's skin is pink, warm, and dry e. the assistive personnel reports that the client walked with a limp

A. respiratory rate is 22/min with even unlabored respirations C. clients pain rating is a 3 on a scale of 0-10 d. the clients skin is pink, warm, and dry

independent interventions

Activities that nurses are licensed to initiate on the basis of their knowledge and skills

A client with diarrhea also has a primary care provider's order for a bulk laxative daily. The nurse, not realizing that bulk laxatives can help solidify certain types of diarrhea, concludes, :The primary care provider does not know the client has diarrhea." What type of statement is this? 1. A fact 2. An inference 3. A judgement 4. An opinion

An inference

Techniques of critical thinking

Critical analysis Socratic Questioning Inductive and deductive reasoning Making valid inferences Differentiating facts from opinions Evaluating the credibility of information sources Clarifying concepts Recognizing assumptions

inductive vs. deductive reasoning

Inductive: Developing generalizations from specific observations ex. nurse sees certain symptoms, reasons that client has condition Deductive: Developing specific predictions from general principles ex. all children love pb&j sandwiches, nurse should give child that doesn't want to eat a pb&j

Example of nursing diagnosis

Ineffective airway clearance related to asthma as evidenced by dyspnea, wheezes, and restlessness

Alfaro-LeFevre's 4-Circle Critical Thinking Model

Provides a visual representation of critical thinking abilities and promotes making meaningful connections b/t nursing's research and positions on critical thinking and practice

clinical reasoning

The cognitive process that uses thinking strategies to gather and analyze client information, evaluate the relevance of the information, and decide on possible nursing actions to improve the client's physiological and psychosocial outcomes.

Clinical Judgement

a decision making process to ascertain the right time in the client's care.

Concept mapping

a technique that uses a graphic depiction of nonlinear and linear relationships to represent critical thinking also known as mind mapping

a nurse uses head to toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? a. Confidence b. Perseverance c. Integrity d. Discipline

a. Discipline

The nurse is conducting the diagnosing phase of the nursing process for a client with a seizure disorder. Which steps exist between data analysis and formulating the diagnostic statement? a. assess the client needs b. delineate the clients problems and strengths c. determine which interventions are most likely to succeed d. estimate the cost of several different approaches

a. delineate the client's problems and strengths

which of the following is the purpose of assessing? a. establish a database of client responses to his or her health status b. identify clients strengths and problems c. develop an individualized plan of care d. implement care, prevent illness, and prevent Wellness

a. establish a database of client responses to his or her health status

a nurse is discussing the nursing process with the newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? a. I will determine the most important client problems that we should address b. I will review the past medical history on the client's record to get more information c. I will carry up the new prescriptions from the provider d. I will ask the client if their nausea has been resolved

a. i will determine the most important client problems that we should address

Which behavior is most representative of the nursing diagnosis phase of the nursing process? a. identifying major problems or needs b. organizing data in the client's family history c. establishing short term and long term goals d. administering an antibiotic

a. identifying major problems or needs

a collaborative problem is indicated instead of a nursing or medical diagnosis a. if both medical and nursing interventions are required to treat the problem b. when the independent nursing actions can be utilized to treat the problem c. in cases where the nursing interventions are primary actions required to treat the problem d. when no medical diagnosis can be determined

a. if both medical and nursing interventions are required to treat the problem

a major characteristic of the nursing process is which of the following? a. Its focus on client needs b. it's static nature c. an emphasis on Physiology and illness d. it's exclusive used by and with nurses

a. its focus on the clients needs

which nursing diagnosis contains the proper components? a. potential for impairment in caregiver role related to unpredictable illness course b. potential for falls related to tendency to collapse when having difficulty breathing c. altered communication related to stroke d. altered sleep secondary to fatigue and a noisy environment

a. potential for impairment in caregiver role related to unpredictable illness course

in the case in which a client is vulnerable to developing a health problem, the nurse chooses which type of nursing diagnosis status? a. a risk nursing diagnosis b. a syndrome nursing diagnosis c. a health promotion nursing diagnosis d. an actual nursing diagnosis

a. risk nursing diagnosis

which of the following would indicate a significant cue when comparing data to standards? Select all that apply a. the client has moved partway toward a set goal b. a child is able to control bladder and bowels at age 18 months c. a recently widowed woman states she is "unable to cry" d. a 16 year old high school student reports spending six hours doing homework five nights per week

a. the client has moved partway toward a set goal c. a recently widowed woman states she is "unable to cry" d. a 16 year old high school student reports spending six hours doing homework 5 nights a week

dependent interventions

activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses.

nursing intervention

any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient/client outcomes

Nursing process

assessment, diagnosis, outcome identification, planning, implementation, evaluation systematic, rational method of planning and providing individualized nursing care.

the diagnostic statement "increased fluid volume related to decreased venous return as manifested by lower extremity edema (swelling), " the etiology of the problem is which of the following? a. increased fluid volume b. decreased venous return c. edema d. unknown

b. decreased venous return

which of the following represent effective planning of the interview setting? select all that apply a. keep the lighting dim so it's not distressed the client eyes b. ensure that no one can overhear the interview conversation c. stand near the clients head while he or she is in a bed or chair d. keep approximately 3 feet from the client during the interview e. use standard form to be sure all relevant data are covered in the interview

b. ensure that no one can overhear the interview conversation d. keep approximately 3 feet from the client during the interview e. use standard form to be sure all relevant data are covered in the interview

A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the clients medical record, discovers the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? a. Fairness b. Responsibility c. risk taking d. creativity

b. responsibility

which element is best categorized as secondary subjective data? a. the nurse measures a weight loss of 10 pounds since the last clinic visit b. spouse states the client has lost all appetite c. the nurse palpates edema in lower extremities d. client states severe pain when walking up stairs

b. spouse states the client has lost all appetite

in the validating activity of the assessing phase of the nurse process, the nurse performs which of the following? a. collect subjective data b. applies a framework to the collective data c. confirms that data are complete and accurate d. records data in client record

c. confirms that data is complete and accurate

which statement is true regarding the state of the science in regard to nursing diagnosis? a. the original taxonomy has proven to be adequate in scope b. the organizing framework of the taxonomy is based on the work of Florence Nightingale c. more research is needed to validate and refine the diagnostic labels d. new diagnostic labels are approved by means of a vote of registered nurses

c. more research is needed to validate and refine the diagnostic labels

which behavior would indicate the nurse was utilizing the assessment phase of the nursing process to provide nursing care? a. Proposes hypotheses b. generate desired outcomes c. reviews results of laboratory tests d. documents care

c. review results of lab tests

a charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a providers prescription. Which of the following interventions should the charge nurse include (select all that apply) a. writing a prescription for morphine sulfate as needed for pain b. inserting a nasogastric tube to relieve gastric distention c. showing a client how to use progressive muscle relaxation d. performing a daily bath after the evening meal e. repositioning a client every two hours to reduce pressure injury risk

c. showing a client how to use progressive muscle relaxation d. performing a daily bath after the evening meal e. repositioning a client every two hours to reduce pressure injury risk

the nurse wishes to determine the clients feelings about a recent diagnosis. Which interview question is most likely to elicit this information? a. what did the doctor tell you about your diagnosis? b. are you worried about how the diagnosis will affect you in the future? c. tell me about your reactions to the diagnosis d. how is your family responding to the diagnosis?

c. tell me your reactions to the diagnosis

actual nursing diagnosis

client problem that is present at the time of the nursing assessment

risk nursing diagnosis

clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene

syndrome diagnosis

clinical nursing judgement when a client has several similar nursing diagnoses.

skills required for implementation phase

cognitive skills interpersonal skills technical skills

evaluating statement is made up of two parts

conclusion and supporting data ex: goal was met: oral intake 300 mL more than output: skin turgor resilient, mucous membranes moist

the use of conceptual or theoretical framework for collecting and organizing assessment data ensures which of the following? a. correlation of the data with other members of the health care team b. demonstration of cost effective care c. utilization of creativity and intuition and creating a plan of care d. collection of all necessary information for a thorough appraisal

d. collection of all necessary information for a thorough appraisal

which statement would be true regarding the use of the observing method of data collection? a. When observing the nurse uses only the visual sense b. observing is done only when no other nursing interventions are being performed at the same time c. data should be gathered as they occur, rather than in any particular order d. observed data should be interpreted in relation to other sources of collected data

d. observed data should be interpreted in relation to other sources of collected data

one of the primary advantages of using a three part diagnostic statement such as the problem etiology signs and symptoms format includes which of the following? a. decreases the cost of healthcare b. improves communication between nursing client c. helps the nurse focus on health and Wellness elements d. standardizes organization of client data

d. standardizes organization of client data

Nursing Interventions Classification (NIC)

first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties and facilitates the work of identifying appropriate interventions •Consists of three levels -Level 1 ▪Domains -Level 2 ▪Classes -Level 3 ▪Interventions

4 types of concept maps

hierarchical spider maps flow chart maps system maps

Critical thinking attitudes

independence- think for themselves not easily swayed Fair mindedness- impartial judgements Insight into egocentricity- understand that their experiences might cause bias in thinking intellectual humility- awareness of limits of ones own knowledge Intellectual courage to challenge status quo or rituals- examine fairly ones own ideas or views Integrity- able to admit and evaluate inconsistencies in their own beliefs and change based on situation Perseverance- determination to finding the best/right answer despite frustrations and hardships Confidence- well reasoned thinking will lead to trustworthy conclusions Curiosity- critical thinker mind is filled with questions

Types of Nursing Interventions

independent, dependent, collaborative

different types of care plans

informal care plan- strategy for action that exists in the nurses mind formal care plan- written or computerized guide that organizes information about the client's care standardized care plan- formal nursing plan that specifies care for groups of clients with common needs individualized care plan- tailored to meet the unique needs to a specific client

Problem solving

mental activity in which a problem is identified that represents an unsteady state

Intuition

problem solving approach that relies on a nurse's inner sense.

health promotion diagnosis

relates to clients' preparedness to implement behaviors to improve their health condition

diagnosis

statement or conclusion regarding the nature of a phenomenon

defining characteristics

the cluster of signs and symptoms that indicate the presence of a particular diagnostic label

medical diagnosis vs nursing diagnosis

the medical diagnosis refers to disease processes, made by a physician and refers to a condition only a physician can treat. the nursing diagnosis is a statement of clinical judgement that concerns human response to a condition that nurses are licensed to treat

Discharge planning

the process of anticipating and planning for client needs after discharge

Critical Thinking

the process of intentionally higher thinking to define a client problem, examine evidence based practice in caring for the client, and make choices in the delivery of care

The Planning Process

•Consists of the following activities: -Setting priorities -Establishing client goals/desired outcomes -Selecting nursing interventions -Writing individualized nursing interventions on care plans

Evaluating

•Judgment and appraisal •Planned, ongoing, purposeful activity •Determines client's progress, effectiveness of care plan •Continuous process •Demonstrates nursing responsibility and accountability for their actions

collaborative interventions

▪Actions nurse carries out in collaboration with other health team members ▪Reflect overlapping responsibilities of healthcare team