chapter 2

One characteristic of a nurse who is a critical thinker is the ability to

validate information and judgments.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis for a support group at the local hospital for clients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following?

A referral

What is pivotal to determining how to move from each client problem to its goals?

Clinical reasoning process

Revising the plan as needed occurs in what part of the nursing process?

Evaluation

A nursing instructor is describing why data analysis is considered a very difficult step in the nursing process. Which of the following would the instructor identify?

It requires diagnostic reasoning skills.

When documenting clinical data after an assessment of the client's neck, what might you write in the physical assessment?

Thyroid isthmus barely palpable, lobes not felt

A nurse has just admitted a client who has a wound infection to the unit. After assessing the client, the next step of the nursing process the nurse should perform is:

analyze the data

The nurse prepares a genogram after collecting health history information from a client. For which part of the history is this diagram beneficial?

analyze the data

The nurse is developing goals after completing the assessment of a newly admitted medical client. The nurse would document the goals under which part of the nursing process?

planning

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.

seeing things as only right or wrong

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?

nursing diagnosis

A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response?

"It's acceptable for a client to be admitted for observation."

The nurse is attempting to cluster the data collected during the initial assessment of an older adult client. The nurse notes that the client had a swollen left knee and complained of "a bit of soreness" in the joint, but the nurse does not have enough data to support a nursing diagnosis of Impaired Physical Mobility. What should the nurse do next?

Assess the client further for evidence of reduced mobility and decreased range of motion.

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data?

Anxious appearance

Which of the following would be most important for a nurse when developing critical thinking skills?

Maintenance of an open mind

A nurse recognizes that a thorough and accurate assessment of a client is important to prevent what error from occurring when utilizing the nursing process?

Making incorrect nursing judgments or diagnoses

A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case?

Overlooking consideration of the clients cultural background

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessment on a client who is complaining of shortness of breath.

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action?

Review the client's prescribed medication orders.

Which statement would demonstrate the correct method for writing an evaluation of client progress after implementing the nursing process?

client ambulated 3/3 times during a planned 8-hour period

The nurse realizes that after she confirms that the cluster data collected meet the characteristics of a certain diagnosis, the next step is to do which of the following?

tell the client what you perceive the diagnosis to be