Module 1 (Nursing Process, Health & Wellness, Healthcare Delivery)

A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the clients care requires clinical reason when it is complicated by which of the following factors?

Complex clinical situations, ongoing client and family concerns rationale: Clinical reasoning is necessary when determining the prioritization of important clinical issues over issues that can wait. For example, clients who have broken bones as well as a compromised airway need their airway to be stabilized prior to setting broken bones. Correct prioritization is a key part of clinical reasoning in complex care settings. Client and family concerns complicate the clinical situation of the client's care, making clinical reasoning a necessity. Clients and family members can reveal important pieces of information as they express their concerns. The nurse needs to carefully listen to everything that clients and their families say to collect information that might be useful in providing optimal care to the client.

A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make?

Critical thinking is the foundation for clinical decision making rationale: It is a critical component of nursing care and is used in each step of the nursing process to enhance client care.

Diagnosis

analyze, validate and cluster patient data to identify patient problems.

A nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using?

assessment rationale: Auscultating the client's lung sounds is part of a physical assessment.

Evaluation

determine whether the patient's goals are met, examine the effectiveness of interventions, and decide whether the plan of vare should be discontinued, continued or revised.

A nurse asked the client to write the current level of pain using a scale of 0 to 10 after administering a pain medication 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

evaluation rationale: The nurse is using the evaluation step of the nursing process by collecting subjective data from the client using an established pain scale to compare the client's current pain level to their original level of pain.

A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process?

planning rationale: In the planning step of the nursing process, the nurse develops interventions to treat or manage the client's identified problems. The plan of care guides the treatment of the client and should be modified as the client's condition changes. In this scenario, the nurse is making goals for the client regarding ambulation.

Disease prevention

primary and secondary (early detection) preventive measures aimed at reducing the burden of disease and associated risk factors.

Planning

prioritize the nursing diagnoses and identifies short and long term goals that are realistic, measurable and patient focused with outcome identification for evaluation purposes.

primary prevention

the act of intervening before negative health effects occur

Health promotion

the process of enhancing people's influence over and improvement of their health.

A nurse is caring for a client who has been wheezing. The nurse asked an assistive personnel do use a stethoscope and listen to the clients lung sounds to determine if their wheezing has improved. This is an example of which of the following concepts?

Delegation of the wrong task rationale: stethoscope and listening to lung sounds is not within the range of a function of an AP

A nurse is reviewing methods created to assist nurses in using evidence-based practice. Which of the following is a NCSBN model that can assist the nurse is critical thinking and decision making?

Clinical judgment rationale: The Clinical Judgment Model was developed to assist nurses in using evidence-based practice to think critically and make decisions.

Implementation

initiate specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes.

Levels of Prevention

primary, secondary, tertiary

secondary prevention

the detection and treatment of preclinical changes to reduce the impact of disease or injury and limit disability

nursing process

Assessment Diagnosis Planning Implementation Evaluation

A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion?

Inference, creativity, inductive reasoning

tertiary prevention

aims to reverse, minimize, or delay the effects of a disease or disability.

Assessment

gathered patient care data through observation, interviews and physical assessment.

In what order should an RN perform the steps of the nursing process?

Assessment, analysis, planning, implementation, evaluation

A charge nurse is planning to discuss factors that can influence the clinical decision making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include?

Available resources, awareness of client status, support from other staff rationale: Resources are factors that can influence the decision-making process, which is used as the framework for developing the plan of care. The nurse's awareness of the client's status is a factor that can influence the decision-making process, which is used as the framework for developing the plan of care. The availability of support from other staff is a factor that can influence the decision-making process, which is used as the framework for developing the plan of care.