CH. 15-17
During a visit to the clinic, a patient tells the nurse the has has been sick to his stomach for 3 days, and he vomited twice yesterday. Which response by the nurse is an example of probing?
"Is there anything else bothering you?"
A pregnant patient with epilepsy was prescribed phenytoin, which is teratogenic. Which critical action would the nurse take?
Question the prescription
Which method would the student nurse use to reflect on and analyze the student's own thoughts, actions, and knowledge?
Reflective journaling
Which term describes data that appear to show some type of patterned relationship with a nursing diagnosis?
Related factors
According to Gordon's model, which health pattern describes the patient's spiritual attitude?
Value-belief pattern
The student nurse is assigned to check the blood pressure of a patient and refers to the manual before doing so. When level of thinking does this illustrate?
basic
A 40-year-old patient is admitted with severe pain in the lower abdomen. A newly hired nurse is assigned to care for this patient. Which level of critical thinking according to Kataoka-Yahiro and Saylor's model would the nurse use?
basic complex commitment
When performing the initial interview for patient admitted to the hospital, which characteristic of the patient should the nurse document as objective data?
body temperature of 104 degrees fahrenheit (40 degrees celsius) a raised, red, swelling on the back drainage from wounds on the right hand and and the right foot
In the examples given, which nurse is making a nursing diagnostic error?
A nurse assesses the edema in a patient's lower leg and is unsure how to assess the severity of the edema A nurse identifies a diagnosis based on a single defining characteristic A nurse identifies a risk diagnosis related to a medical diagnosis
Which word does the P in the acronym PES stand for?
problem
Which skill is unique to the commitment level of critical thinking?
Anticipating when to make choices without others' assistance
A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. Which level of critical thinking is the nurse using?
Basic critical thinking
The nurse assessing a patient with genital lesions suspects the patient has multiple sexual partners. How would the nurse obtain more information from the patient?
Be honest Use tact Ask objective questions.
A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff responds, but the patient dies 30 minutes later. The manager of the nursing unit calls a meeting of the nursing staff involved in the emergency response. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. In this situation, which action are the nurses performing?
Conducting reflective practice
Which will help the nurse apply critical thinking skills in the day-to-day routine in an acute care setting
Discipline Responsibility Perseverance
A patient complains of pain when swallowing solid food. The nurse asks the patient if he or she has a history of substance abuse that has caused this pain. Which diagnostic error does the nurse make in this scenario?
Error in data collection
Which errors may occur when the nurse makes the nursing diagnosis prior to grouping all data?
Errors in the diagnostic statement
Arrange the different steps of a problem-oriented approach for comprehensive assessment in the appropriate order
Focus on the patient's present situation Ask follow-up questions. Conduct a physical assessment Analyze the nature of the patient's problem Develop a care plan.
Which clinical judgment concerns motivation and desire to increase well-being and actualize human health potential?
Health promotion nursing diagnosis
Which question does the nurse ask the patient with a renal disorder while selecting nursing diagnoses relevant to the patient's culture?
How does this health problem affect you and your family?
A patient has undergone a major surgery. In the immediate postoperative period, the patient's blood pressure suddenly falls, his pulse becomes rapid, and he loses consciousness. Which postoperative complication would the nurse suspect?
Internal hemorrhage resulting from surgery
An incorrect nursing diagnosis could lead to which factor?
It could affect the quality of patient care
Which statement indicates effective learning regarding the application of nursing diagnoses to care planning?
Nursing diagnoses direct the planning process and the selection of nursing interventions. A nursing diagnosis of damaged skin directs a nurse to apply a support surface to a patient's bed and initiate a turning schedule.
A patient with diabetes has come to the nurse with symptoms suggestive of hypoglycemia. Which action would be the first appropriate nursing intervention?
Offer foods rich in glucose.
Which statement by the students indicates effective learning regarding medical diagnoses?
Osteoarthritis is a medical diagnosis. Medical diagnoses are based on the results of diagnostic tests. A health care provider is licensed to describe medical diagnoses.
The nurse wishes to use critical thinking skills in clinical practice. Which trait is an obstacle to the development of critical thinking?
Overconfidence Biased views Failure to accept mistakes
A patient's caregiver asks the nurse, "Can I view the patient's medical records?" Which action would the nurse take?
Politely tell the caregiver that disclosing the medical records to others is not in accordance with the law
The nurse is interviewing a patient who comes into the emergency department with a headache of 5 days' duration. Which question from the nurse is an example of a closed-ended question?
"Do you have pain now? Is your headache severe?" Are you frightened that the diagnosis will be cancer?"
During a home health visit, the nurse prepares to instruct a patient on how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before the nurse's arrival. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." Which statement by the nurse illustrates the critical thinking attitude of integrity?
"I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax."
Which statement made by a student indicates the need for further teaching regarding the application of nursing diagnoses to clinical practice?
"Nursing diagnoses improve the selection of nursing interventions by nurses in certain practice settings."
Which statement by the students indicates effective learning regarding medical diagnoses?
"Osteoarthritis is a medical diagnosis." "Medical diagnoses are based on the results of diagnostic tests." "A health care provider is licensed to describe medical diagnoses."
Which statement is true regarding a related factor?
A related factor is within the domain of nursing practice In the case of a risk nursing diagnosis, a risk factor is the related factor A related factor is identified from the patient's assessment data
A patient complains of nausea and vomiting after consuming food stored for a long time. The nurse suggests that the patient take the antiemetic agent metoclopramide, but the patient asks the nurse if the problem could be managed by taking a ginger supplement. The nurse knows that ginger is equally effective in controlling nausea and vomiting. How would the nurse ensure patient safety?
Accept multiple solutions Reflect on the nurse's own judgment Tell the patient that multiple solutions exist
Which action would prevent errors in interpretation when making a nursing diagnosis?
Accurately interpreting cues Using reliable cues Considering cultural influences or developmental stage
Which point would the nurse consider when formulating the nursing diagnosis?
Accurately selecting the diagnoses Identifying related factors pertinent to the diagnosis Selecting interventions suited for treating the diagnosed condition Identifying defining characteristics of the diagnosis
Which action shown by the registered nurse reflects integrity?
Admitting own mistakes
Which related factor could be used for a potential diagnosis for pressure ulcers?
Age extremes Fluid retention Impaired sensation Physical immobilizatio
The nurse finds that a surgical patient has incision pain, fever, and nausea. Based on the findings, the nurse concludes that the patient has infection at the surgical site. Which critical thinking skill has the nurse applied?
Analysis
A male patient underwent a prostatectomy and expresses that he is experiencing some pain and discomfort. The nursing student examines the patient's wound. Which describes a good critical thinker? Select all that apply.
Analytic Systematic Inquisitive
The nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, "I feel funny." The nurse knows how patients often have behavioral changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse calls the physician and begins the conversation by saying, "I believe the patient is developing sepsis. I want to report symptoms I'm seeing." Which critical thinking concept does the nurse show?
Analyticity Self-confidence
Which activity is involved in the assessment phase of the nursing process?
Asking the patient about the complaint Inquiring about the patient's current medication Asking about the patient's past and family medical history
How would the nurse arrange the steps in the correct sequence for making a nursing diagnosis for a patient with asthma?
Assessing the patient's health status Validating data with other sources Clustering the data Selecting the diagnostic label
The nurse is attending to a patient in a coronary care unit. The nurse is revising the care plan after evaluating the patient outcomes. Which step of the nursing process is the nurse performing?
Assessment Evaluation
The nurse understands that interpretation is an important skill in critical thinking. In which activity can the nurse implement interpretation skills?
Being orderly in data collection Looking for patterns to categorize data Clarifying any doubtful data
Which type of interview technique is the nurse demonstrating when asking the questions, "Do you have pain or cramping?" or "Does the pain get worse when you walk?"
Closed-ended questioning Problem-oriented questioning
According to North American Nursing Diagnosis Association International (NANDA-I), which category of sources of error may occur in the nursing diagnostic process?
Collecting Clustering Interpreting
A patient is admitted with severe pain in the lower abdomen and is very uncomfortable. Which attitude of critical thinking would the student nurse adopt when approaching the patient?
Confidence
The postoperative patient expresses to the nursing student that he is experiencing some pain and discomfort. The nursing student examines the patient's wound. The patient also tells the nurse that another nurse visited him a while ago but was rude and did not pay any attention to him. The nursing student apologizes and assures him that his needs are fulfilled. The student speaks to the co-worker and manages the situation. Which attitude for critical thinking did the nursing student display here?
Confidence
The nurse observes a student nurse caring for a patient with diarrhea. Which quality in the student nurse reflects cognitive maturity?
Considering multiple solutions for the patient's condition
The nurse is designing a care plan for a patient admitted to the hospital with pneumonia. The patient is a smoker. The nurse is using the PES format (problem, etiology, and symptom) for formulating nursing diagnoses. Which component can the nurse include in this PES format?
Cough and shortness of breath Dyspnea or difficulty in breathing Problems caused by smoking
Which step is essential for decision-making in a diagnostic process?
Data clustering Formulating the diagnosis Identifying patient health problems
The nurse is designing a plan of care for a patient who is has been diagnosed with pneumonia. The nurse determines that the patient is experiencing impaired gas exchange in the lungs. Which component of the assessment data can be part of the related factors for this patient?
Decreased ventilatory effort caused by fatigue Accumulation of secretions within the alveoli
Which statement made by the student nurse indicates the need for further education regarding North American Nursing Diagnosis Association International (NANDA-I) terminologies in the medical record entry?
Diagnoses do not take into consideration evidence-based diagnoses Diagnoses are refined by the health care provider on a regular basis
A patient is admitted to the hospital for severe dehydration. The nurse asks the patient about bowel movements, urine output, and sweating. On the basis of Gordon's functional health patterns, which pattern is the nurse assessing?
Elimination pattern
During the 12-hour shift, a patient had 40 mL of drainage in the surgical drainage collection device. The nurse refers to the written plan of care and notes that the health care provider should be informed when drainage in the device exceeds 100 mL for the day. Which type of action is the nurse performing when observing the drainage volume in the device to determine if it has exceeded the prescribed daily maximum?
Evaluation
The nurse is caring for a football player scheduled for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient's voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play postsurgery. Which intervention would the nurse implement to reduce anxiety in the patient?
Explain the recovery process to the patient. Provide detailed instructions about the surgery Teach postoperative care to the patient and his caregiver
The nurse is caring for a football player scheduled for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient's voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play postsurgery. Which intervention would the nurse implement to reduce anxiety in the patient?
Explain the recovery process to the patient. Provide detailed instructions about the surgery. Teach postoperative care to the patient and his caregiver.
Which diagnostic error may lead to an error in nursing diagnosis?
Failure to seek guidance when the nurse has doubts Premature or early closure of clustering Selection of the wrong diagnostic label Failure to consider conflicting cues
The nurse has been assigned to care for a patient admitted to the hospital. Which activity is included in the orientation phase of an interview?
Greet the patient using his or her full name. Introduce yourself, and explain your role Ensure privacy by closing the door of the room or shutting the curtains
The nurse assesses a patient who comes to the pulmonary clinic: "I see that it has been more than 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also, I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following this plan?" The nurse's assessment covers which of Gordon's functional health patterns?
Health perception and management
A group of nurses is organizing an educational session to teach the population of a particular community about the roots of cardiovascular disease and its effect on the human body. Which type of nursing diagnosis is being followed in this scenario?
Health promotion nursing diagnosis
A patient has arrived at the emergency department (ED) complaining of fatigue and memory loss. While performing the health assessment, which back-channeling technique may the nurse use during the patient interview?
I see Go on Maintain good eye contact, and show interest in what the patient is saying.
Which action would the nurse take when preparing a diagnostic statement for a patient who has diabetes?
Identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom.
Which guideline would the nurse follow to reduce errors in the diagnostic statement?
Identify treatable etiologies or risk factors Identify the problems caused by the treatment Identify the patient's response
The steps of the scientific method in the correct sequence.
Identifying the problem Collecting data Formulating a question or hypothesis Testing the question or hypothesis Evaluating results of the study
Arrange the steps of the scientific method of critical thinking in the correct order.
Identifying the problem Collecting essential data Formulating questions Requesting diagnostic tests Diagnosing the problem
Which nursing diagnosis will the nurse select upon auscultating wheezing breath sounds in a patient with exercise-induced asthma when the clinic uses the International Classification for Nursing Practice (ICNP) terminology system?
Impaired respiratory system
Which describes an example of an interpreting error in nursing diagnostics?
Inaccurate understanding of cue
The nurse speaks with a patient who lost a sister 2 weeks ago. The patient is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks the patient to clarify the type of trouble. The patient explains she cannot concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. Of which skill is this an example?
Inference
A patient diagnosed with pancreatitis complains of pain in the abdomen. The patient has vomited 3 times, and has a temperature of 101° F. After an initial interview and assessment, the nurse prepares a nursing care plan. The nurse formulates a diagnosis of acute pain. Which symptom could be the related factor for this diagnostic label?
Inflammation of the pancreas
Which statement describes a health promotion diagnosis, according to North American Nursing Diagnosis Association International (NANDA-I)?
It describes a person's readiness to enhance specific health behaviors for well-being
An accurate nursing diagnosis leads to which benefit?
It helps ensure effective and efficient nursing interventions.
The nurse asks a patient how she feels about her impending surgery. Before the discussion, the nurse reviewed the textbook description of loss, grief, and therapeutic communication principles. Which critical thinking component did the nurse use while reviewing the literature?
Knowledge application
Which assessment activity reflects effective communication skills during a patient-centered interview?
Meet and acknowledge visitors in the patient's room. Sit next to the patient Ask the patient to summarize the discussion Ask, "How would you prefer I address you? Ask for permission to conduct the interview Say, "Tell me how you want us to help you
A mother finds her 26-year-old daughter unconscious at home. She is taken to the hospital by ambulance while the mother and her 1-year-old granddaughter follow. Who would be the primary source of information in this case?
Mother
The nurse is assessing a patient with diabetes. Which data collected by the nurse is subjective data?
Nausea with duration of 2 hours Tingling sensation in the feet
Which statement by a student indicates the need for further learning regarding the use of a standard formal nursing diagnostic statement from North American Nursing Diagnosis Association International (NANDA-I)?
Nursing diagnoses emphasize following traditional practice guidelines." These statements align the role of the nurses with other health care providers. Nursing diagnoses help the nurses focus on the scope of medical practice as a whole.
The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that when she took her mother to the store they became separated, and the mother could not find the front entrance. The daughter works part-time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern?
Pacing Patient getting lost easily The patient getting up frequently
Which problem is a collaborative problem?
Paralysis Hemorrhage Wound infection
During a review of systems for a nursing history, the nurse learns that the patient has been coughing up mucus. Which nursing assessment would be best for the nurse to use to confirm a lung problem?
Physical examination with auscultation of the lungs Medical record summary of x-ray film findings
During a review of systems for a nursing history, the nurse learns that the patient has been coughing up mucus. Which nursing assessment would be best for the nurse to use to confirm a lung problem? S
Physical examination with auscultation of the lungs Medical record summary of x-ray film findings
As per Yura and Walsh, which describes a component of the nursing process?
Planning Evaluation Assessment Implementation
A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment?
Problem focused
A patient is anxious about an operation scheduled for the next day. Which intervention does the nurse use to decrease the patient's anxiety related to surgery?
Provide satisfactory answers to the patient's questions. Provide detailed instructions about the recovery process. Provide detailed instructions about the surgical procedure.
A patient complains of epigastric pain. The nurse assumes the problem is gastritis and educates the patient about the condition. The patient is later diagnosed with mild myocardial infarction. Which action would indicate appropriate management of the situation?
Providing a straightforward explanation to the patient for why the confusion occurred Remembering the need to be open-minded while looking at the patient's information during the initial diagnosis Retroactively correlating the patient's data to see what was missed
The nurse in the postoperative ward has two tasks at hand. A urine sample has to be dispatched, and a patient needs to ambulate down the hallway. Meanwhile another patient experiences a sudden drop in blood pressure associated with altered consciousness. Which nursing action is appropriate?
Providing care to the patient who is experiencing falling blood pressure
In which order would the nurse record the data from a patient's assessment and formulate the nursing diagnosis?
Record symptoms Assess for related factors Identify patient needs Formulate the nursing diagnosis
The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. Which component is the E in a three-part nursing diagnostic statement using the PES format?
Related to incisional trauma
The nurse is assessing patients on the unit. Which activity would the nurse perform during the diagnostic phase of the nursing process?
Review information collected about the patient. Find cues and patterns in the patient's data Make conclusions related to health problems
Which statement identifies different types of nursing diagnoses, according to North American Nursing Diagnosis Association International (NANDA-I)?
Risk diagnoses Problem-focused diagnoses Health promotion diagnoses
The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. Which component is the P in a three-part nursing diagnostic statement using the PES format?
Severe pain
According to North American Nursing Diagnosis Association International (NANDA-I) diagnoses, under which category would the nurse classify related factors?
Situational Maturational Treatment-related Pathophysiological
The nurse is caring for a patient with a pressure ulcer on his left hip. The nurse asks the patient several questions to determine how he may have gotten the pressure ulcer. Which of the 11 functional health patterns from Gordon's model should the nurse address in her assessment?
Sleep-rest pattern Elimination pattern Nutritional-metabolic pattern
A patient reports severe abdominal pain in the right iliac region. The nurse is completing the nursing history. Which information would the nurse elicit to help arrive at the probable cause of abdominal pain?
Some questions about the digestive system
Which word does the S in PES stand for?
Symptoms
Which related factor falls under health promotion nursing diagnosis?
The patient is willing to eat nutritious foods The patient is ready to increase his or her coping skills The patient is ready to perform regular exercises
The nurse received the Employee of the Year award for knowledge, courage, honesty, and objectivity. Which concept of critical thinking does the nurse possess, according to Facione and Facione?
Truth seeking
A patient who received penicillin developed a rash on the right hand. The patient asked the nurse why the rash developed. How would the nurse explain this to the patient?
Use previous knowledge
Which statement accurately describes the process of validating data?
Validate the findings with information from the patient's family Validate with findings from a physical examination Validate by asking the patient directly Validate by contacting the patient's previous doctor
Which statement accurately describes the process of validating data?
Validate the findings with information from the patient's family Validate with findings from a physical examination Validate by asking the patient directly. Validate by contacting the patient's previous doctor
The nurse is caring for a football player hospitalized for ankle surgery. The patient communicates properly during the interview. The nurse finds a quiver in the patient's voice as he expresses his worry about not being able to play. The nurse observes that the patient has fidgety hands and legs. The nurse concludes that the patient is uncertain about his ability to play postsurgery. Which data cluster helps the nurse determine anxiety is present?
Verbal expression of worry Fidgety hands and legs A quiver in the patient's voice while talking
The nurse is caring for a patient with diabetes mellitus. The nurse uses diagnostic reasoning to determine the patient's health problems. Which parameter would the nurse include when using diagnostic reasoning for this patient?
Weakness Light-headedness Blurred vision
The nurse is beginning the interview of a patient who complains of a backache. Which question is appropriate for the nurse to ask first?
What brings you to the hospital today?
The nurse is caring for a patient who has been admitted to the hospital with pneumonia. Which assessment finding of the patient can the nurse use to formulate a data cluster?
Wheezing in left lung bases Respiration 20 breaths/min Shortness of breath with ambulation
The nurse is conducting the initial assessment of an elderly patient admitted to the hospital with diabetes mellitus. Which assessment question should the nurse ask when obtaining data about the patient's cognitive-perceptual pattern?
Who is the current president? What is the date? What is the year?
The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. Which component is the S in a three-part nursing diagnostic statement using the PES format?
Wincing, guarding, and restricted turning and positioning
A patient is scheduled for a prostatectomy. The patient is worried that he may not be able to have sex after surgery. Which response by the nurse is appropriate?
Your surgeon will talk to you about the surgery. Don't be afraid to ask this question."
A night shift nurse has taken over for the nurse from the previous shift. There are four new patients, and the nurse needs to interview them to complete the nursing histories. When would the nurse plan to interview these patients?
after reviewing the information given in the change-of shift report
According to R.W. Paul, which intellectual standards should the nurse have for critical thinking?
clear plausible complete
Which attitude is essential for critical thinking?
confidence fairness discipline curiosity
The nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. In which option does the nurse avoid an error?
data interpretation
Which type of interpretation error may occur with a nursing diagnosis?
inaccurate interpretation of cues failure to consider conflicting cues insufficient cluster of cues
Which factor can cause errors in data collection?
missing data inaccurate data disorganization lack of knowledge or skill
Which characteristics are a component of critical thinking?
open-mindedness, continual inquiry, and perseverance recognition of an issue, analysis of related informationm and formation of conclusions imagination and exploration of alternatives, cnsideration of ethical principals, and informed decision-making