Chapter 15-17: fundamentals

A nurse has already set the agenda during a patient-centered interview. What will the nurse do next?

Ask about the chief concerns or problems.

A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up?

Developing nursing diagnoses before completing the database

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

Diagnosis

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What phrase is used to identify what the nurse is doing?

Diagnostic reasoning

A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?

Disruption of tissue integrity

Which method of data collection will the nurse use to establish a patient's database?

Performing a physical examination

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using

Problem-focused assessment

The nurse is gathering data on a patient. Which data will the nurse report as objective data?

Respirations 16

Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.)

Tense muscles Reactive responses Trouble concentrating Very tired feelings

Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient

The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.

A patient expresses fear of going home and being alone. Vital signs are stable, and the incision is nearly completely healed. What can the nurse infer from the subjective data?

The patient is fearful of being discharged.

The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview?

The patient's room with the door closed

After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions?

To distinguish the nurse's role from the physician's role

A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic?

Abdominal distention

Which action should the nurse take to best develop critical thinking skills?

Actively participate in clinical experiences.

A patient presents to the emergency department following a motor vehicle crash that causes a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care?

Acute pain

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved?

Acute pain

While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take?

Adapt the positioning technique to the situation.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make?

Ask the NAP to record the patient's vital signs before administering medications

The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation

Ask the patient about the crying.

While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?

Ask the patient about usual sleep patterns and the onset of having difficulty resting

While completing an admission database, the nurse is interviewing a patient who states, "I am allergic to latex." Which action will the nurse take first?

Ask the patient to describe the type of reaction.

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations?

Ask the patient what causes the facial grimacing with movement

A nurse is pulled from the surgical unit to work on the oncology unit. Which action by the nurse displays humility and responsibility

Asking for an orientation to the unit

Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past

In which order will the nurse use the nursing process steps during the clinical decision-making process

Assessing patient needs Determining nursing diagnoses Planning priorities of care Implementing nursing interventions Evaluating goals

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked, and it has dropped even lower. In which phase of the nursing process did the nurse first make an error

Assessment

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase

Completes a comprehensive database.

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs?

Concept mapping

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Consider cultural differences during this assessment.

Which action should the nurse take when using critical thinking to make clinical decisions?

Consider what is important in a given situation

A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing him or herself with two hands on the water fountain. Which critical thinking attitude did the nurse use in this situation

Creativity

A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document?

Decreased cardiac output related to altered myocardial contractility

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?

Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient?

Deficient fluid volume

A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

Do you feel like you need to go to the bathroom

The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

Etiology

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first?

Explore other options for pain relief.

A nurse is using the problem-focused approach to data collection. Which action will the nurse take first?

Focusing on the patient's presenting situation

A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write?

Health promotion

A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene?

Hemorrhage

Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?

How many bowel movements a day have you had

A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?

Impaired gas exchange related to alveolar-capillary membrane changes

A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)

Impaired physical mobility related to incisional pain Risk for falls related to nursing assistive personnel leaving bedrail down

A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan?

Impaired skin integrity

Which action demonstrates a nurse utilizing reflection to improve clinical decision-making?

Improves a plan of care while thinking back on interventions effectiveness

18. A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following

Institutional practice guidelines

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether there is any history of heart problems. The nurse is utilizing which critical thinking skill?

Interpretation

A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene?

Making a clinical decision based on previous shift assessments

A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise?

Nurse's assumptions about hospital discharge

A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use.

Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma. Organizes data into meaningful clusters. Interprets information from patient Writes a diagnostic label of impaired gas exchange. Writes an etiology.

A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)

Patient describing excitement about discharge Patient's expression of fear regarding upcoming surgery

A nurse is conducting a nursing health history. Which component will the nurse address?

Patient expectations

A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information?

Perform a thorough nursing health history.

A nurse is using the critical thinking skill of evaluation. Which action will the nurse take?

Review the effectiveness of nursing actions.

7. A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions?

Specific knowledge base

Which action indicates a registered nurse is being responsible for making clinical decisions?

Takes immediate action when a patient's condition worsens

A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?

The nurse speaks only to the patient's daughter

A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions

Uses critical thinking for the highest level of quality nursing care

Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions?

Using the nursing process

Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation

Validation involves comparing data with other sources for accuracy

The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask?

What reasons do you think are contributing to your fatigue