Chapter 13

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

A nurse is concerned about the requirements needed to complete all of her courses successfully. Which of the following factors would assist her to be successful?

Implement time-management skills

What type of intervention is the nurse performing when the nurse observes the spouse of a postoperative client performing the client's dressing change?

supervisory

The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the next nursing action?

Assess the client's back visually.

The nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process?

Assessment

Which activity is the clearest example of the evaluation step in the nursing process?

Checking the client's blood pressure 30 minutes after administering captopril

Which action exemplifies the purpose of evaluation in the nursing process?

Decide whether to continue, modify, or terminate client care.

A nurse has developed a plan of care for an adult client. What nursing function is important when using the identified nursing concerns to guide the care of this client?

Prioritize the nursing concerns.

Which is the best example of person-centered care provided by a registered nurse?

Reassuring a client who is anxious about a procedure

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.

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

Reflection

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?

Repositioning the client

The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?

involving the client with all the steps of the process in care development

Self-evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. This process is referred to as:

reflective practice.

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?

Analyze the data and create an individualized nursing concern for care planning.

When using the nursing process, the nurse notes that there is a great deal of overlapping of the steps, with each step flowing into the next. What is the term for this characteristic of the nursing process?

Dynamic

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

Intuition can be a clinically useful adjunct to logical problem solving.

A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process?

Planning

A nurse has completed a client assessment and is preparing to identify appropriate nursing concerns. Which area(s) will the nurse likely address in the nursing concern? Select all that apply.

altered mobility altered nutrition ineffective coping

Put the phases of the nursing process in the correct order. Use all options.

assessment diagnosis planning implementation evaluation