(PrepU) Chapter 13: Blended Competencies, Clinical Reasoning and Processes of Person-Centered Care

The nurse is assessing a 1-year-old baby. The mother states, "I'm not sure if he has a fever. I have such a hard time with my glass thermometer. It's so hard to read." The nurse's best response would be:

"There is some danger in using a glass thermometer and the mercury it contains. You might consider buying a new type of device." Once common, glass mercury thermometers are no longer being used due to the dangers of exposure to mercury.

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?

Activity and rest A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertient for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.

The nurse is caring for an underweight female client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client?

Administer a high-calorie diet, excluding wheat, rye, and oats. Because this client is underweight and has an allergy to wheat, rye, and oats, administering a high-calorie diet and no wheat, rye, and oats would be the most appropriate intervention to meet the specific needs of this client. Administering a multivitamin, monitoring for allergies, and weighing the client as needed are generalized nursing measures and not specific to this client.

A nurse technician is assigned to take clients' vital signs. When making rounds, the nurse notices that one client's vital signs are very different from what they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings?

Assess the client's vital signs again. Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs. The nurse should document assessment findings accurately, completely, concisely, factually, and in a timely manner. To ensure accurate assessment and documentation, the nurse should validate questionable data, not simply document them. Therefore, the nurse should take this client's vital signs again. Asking the nurse technician whether the vital signs are correct would may not be helpful or feasible, as the nurse technician may not know whether the vital signs are accurate or may not be available at this time to consult with the nurse. Moreover, it would be much more efficient for the nurse to simply reassess the client's vital signs. New orders are not needed from the health care provider at this time, as the nurse must first validate the vital signs before taking any further action to address them.

A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process?

Assessment During assessment, the nurse recognizes the existence of cues and conducts a focused data collection. During diagnosis, the nurse clusters cues, interprets the clusters, and validates the diagnoses for accuracy. Planning involves preparing a client plan of care, which directs the activities of the nursing staff in the provision of care. Implementation is the action phase of the nursing process.

A nurse is involved in selecting the appropriate nursing diagnosis for a client. Which techniques would the nurse likely use? Select all that apply.

Cue clustering Cluster interpretation Diagnostic validation The nursing diagnostic process uses cue clustering, cluster interpretation, and diagnostic validation to ensure accuracy in selecting the correct diagnoses for the client. Interviewing and inspection are techniques associated with assessment.

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective. The sequence of the nursing process is assessment, diagnosis, planning, implementation, and evaluation. Checking skin turgor is an assessment. Formulating a care plan is part of planning. Administration of additional fluid occurs during implementation. The nurse evaluates whether the intervention was effective, as demonstrated by a rise in blood pressure and a decline in pulse rate.

Which action should the nurse associate with outcome identification and planning in the nursing process?

Develops an individualized plan of nursing care In the process of outcome identification and planning, the nurse adapts the nursing diagnosis to address the client's strengths, thereby individualizing the plan of care. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care.

A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment?

Document this assessment based on the client's behaviors. Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs. Assessment should be documented accurately, completely, concisely, factually, and in a timely manner. To document factually, the nurse should document the client's behaviors, not the nurse's interpretation of the behaviors. In this situation, the nurse could and should quickly determine whether the client is using a wireless device to communicate with family and then document the client's behavior only if needed. The nurse's observation of the client talking out loud when no one else is in the room is an objective, not subjective, finding (the client reporting hearing voices in the head is an example of a subjective finding, as it is not observable by the nurse). In any case, both objective and subjective findings should be documented.

Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this follow-up with the client, the nurse is in which step of the nursing process?

Evaluation Evaluation is the step of the nursing process in which the nurse evaluates the results of a nursing action. The nurse needs to determine whether the client's pain has been relieved and monitor for any untoward effects. Assessment is the first step, in which the nurse gathers all the information. Planning occurs after information is gathered and the nursing diagnosis is generated. Implementation is the activation of nursing interventions.

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply.

Impaired mobility Imbalanced nutrition Ineffective coping The North American Nursing Diagnosis Association (NANDA)-International defines nursing diagnosis as "a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes." A medical diagnosis describes a disease, whereas a nursing diagnosis describes an individual, family, or group response to an actual or potential health problem. A nursing diagnosis provides the basis for selection of nursing interventions to achieve positive client outcomes.

Which statement best conveys the role of intuition in nurses' problem solving?

Intuition can be a clinically useful adjunct to logical problem solving. Creative, intuitive thinking can be useful supplements to more "in-the-box" methods of problem solving. While it should not be discouraged outright, it should also not be thought of as a replacement for logical or scientific problem solving. Intuition is not dependent on a special "gift" but is thought to be a product of experience and unconscious pattern recognition.

Which is a characteristic of person-centered care?

It is a framework for providing care. The model of person-centered care is a framework for providing care. The approach is not independent of other disciplines, but is interdependent with other disciplines such as medicine, physiotherapy, surgery, etc. The model can be used in all settings and is not limited to hospital settings. Person-centered care aims to provide specific care to people based on individual needs.

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking. Critical thinking is a systematic way of thinking that involves purposeful, outcome-directed thinking. Critical thinking makes judgments based on evidence rather than conjecture. Providing a foundation for evaluation and quality improvement, showing trends and patterns in client status, and supplying validation for reimbursement are functions served by documentation.

What type of learning best takes place in the nursing laboratory?

Kinesthetic learning Learning in the clinical setting or nursing laboratory may be more active, kinesthetic, and random.

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?

Nursing process Although clinical reasoning, reflection, and experience are important components of nursing, the nursing process is recognized as the method of practicing nursing. It is the model on which professional nursing standards are based. Although it sometimes is criticized for not being adaptable to the changing health care environment, the nursing process remains the almost universally accepted method for providing nursing care.

Which is the most appropriate example of the assessment phase of the nursing process?

Palpating a mass in the right lower quadrant of the abdomen Palpation of a mass in the abdominal cavity is an example of assessment in the nursing process through collecting data that determine the need for nursing care. Documentation of medication administration is an intervention. Evaluating the temperature of a client given medication for a fever is a better example of evaluation through assessment. Including a nursing diagnosis in the plan of care is part of determining actual and potential health problems.

Which students study the best in a group setting?

People-oriented learners People-oriented learners are social; they prefer to study in groups rather than alone, and they enjoy the process more than focusing on the task at hand.

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action?

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. There are three types of reflection as defined by Schon: reflection-in-action, reflection-on-action, and reflection-for-action. Reflection-for-action is the desired outcome of the first two types and helps the person to think about how future actions might change as a result of the reflection. When the nurse realizes the need for help turning the client when first attempting to turn the client, this is reflection-in-action. When reflecting whether everyone is using appropriate resources, this is reflection-on-action. When adapting the client's plan of care based on these other reflections, this is reflection-for-action. Turning an obese client without assistance is unsafe and resources should be used. The client's outcomes should not be jeopardized by altering the plan of care due to the time constraints of staffing.

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?

Reflection Reflection is defined as a purposeful activity that leads to action, improvement of practice, and better client outcomes. Memorization is strict learning of material for recall. Assessment is careful observation and evaluation of a client's health status. Evaluation is the assessment and review of the quality and suitability of the care given and the client's responses to that care.

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client. Respect for the client's dignity, and establishing a caring relationship, is furthered by mutual exchange of communication. Approaching care/client as a job, doing things without client input, and doing things your way and efficiently are not necessarily therapeutic, nor do they initiate communication.

The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as

Supervisory The term "supervisory intervention" is applied in the context of overseeing a client's overall care.

A nurse is caring for a client with diabetes mellitus. The client takes insulin 2 times per day. The nurse makes sure the client's meals arrive in coordination with the insulin's effect. The knowledge used by the nurse is:

integrated. This scenario indicates the integration of a nurse's knowledge in the provision of safe client care.

A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as:

life-sized mannequins with a sophisticated computer interface. The human client simulator, a life-sized mannequin with a sophisticated computer interface, presents students with clinical scenarios that evolve based on decisions that students make. The other equipment and devices described are tools used to learn and practice skills, rather than build on critical thinking skills.

A nurse is providing care to an older adult client diagnosed with heart disease. The nurse uses the nursing process to provide individualized care using the actions listed below. Place the actions in the order that the nurse would most likely complete them using the nursing process.

obtains the client's vital signs identifies risk for fluid volume excess develops a realistic goal for monitoring fluid balance prepares an individualized strategy for addressing risk obtains the client's weight daily determines that the client's fluid balance is stabilized When using the nursing process, the nurse follows the steps of assessment (obtaining vital signs), diagnosis (identifying the risk for fluid volume excess), outcome identification (developing realistic and measurable goals), planning (preparing a client plan of care), implementation (carrying out the interventions to achieve the goals), and evaluation (judging the effectiveness of the interventions).