Chapter 5 Thinking Critically to Analyze Data and Make Informed Nursing Judgments

The nurse is caring for an adult client who tells the nurse "For weeks now, I've been so tired. I just can't get to sleep at night because of all the noise in my neighborhood." An actual nursing diagnosis for this client is A. fatigue related to excessive noise levels as manifested by the client's statements of chronic fatigue. B. sleep deprivation related to noisy neighborhood and inability to sleep. C. chronic fatigue syndrome related to excessive levels of noise in neighborhood. D. readiness for enhanced sleep related to control of noise level in the home.

A is correct B is risk diagnosis C, Syndrome diagnosis D. Wellness

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client? A. Weight gain of 3 pounds (1.5 kilograms) over 1-2 days B. Ineffective health maintenance related to having last mammogram 2 years ago C. Knowledge deficit related to lack of information regarding low-sodium diet D. Anxiety related to ineffective coping during hospitalization

A. Nursing diagnoses are based on alterations in body system processes, lifestyle, personal issues, and specific causes. For the client with heart failure, the problem that would have the highest priority would be the weight gain of 3 pounds (1.5 kilograms) over 1-2 days. This change can related to a decline in cardiac functioning and needs to be addressed first. Once this priority problem has been investigated, other problems can be addressed. Ineffective health maintenance can be addressed last. Knowledge deficit related to lack of information regarding low-sodium diet would be the next in priority after activity intolerance because learning how to reduce sodium could help control the heart failure. Anxiety about hospitalization and inability to attend to home and work needs would be addressed after the knowledge deficit.

A nursing student is learning how to use critical thinking in formulating a plan of care. The student understands which of the following to be things needed to demonstrate that the process of thinking critically has begun? (Select all that apply.) A. reserves a final opinion until further collecting data B. explores other alternatives before making a decision C. disregards literature and sound rationale when looking to support own opinion D. uses past knowledge and experience to analyze data

A. B. D

When caring for hospitalized clients, the nurse should recognize which potential safety hazards? (Select all that apply.) A. Call bell on bedside table B. Multiple intravenous infusions C. Bed alarm is on D.Urinary catheter under leg E. Dim lighting

A. B. D. E. The nurse should conduct an initial safety inspection when entering hospitalized clients' rooms. The call bell should be within reach; the client may not be able to reach the bedside table. Multiple infusions poses a risk of medication error. The urinary catheter should not be constricted and should be free flowing to the gravity drainage bag. Dim lighting poses the risk of poor vision and possibly falls. The bed alarm is a safety mechanism to prevent falls and does not pose a greater risk if on. It's helpful to have a bed alarm.

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.) A. Be nonjudgmental and keep an open mind. B. Only validate data that you see, not what the patient tells you. C. Use rationale to support opinions or decisions. D. Do not reflect on your thoughts, just make a decision. E. Acquire an adequate knowledge base that continues to build.

A. C. E. The essential elements of critical thinking are: Keep an open mind, use rationale to support opinions or decisions, reflect on thoughts before reaching a conclusion, use past clinical experiences to build knowledge, acquire an adequate knowledge base that continues to build, be aware of the interactions of others, and be aware of the environment.

A community health nurse provides information to a patient with newly diagnosed multiple sclerosis for a support group at the local hospital for patients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following? A. A referral B. A consultation C. Conferring D. Reporting

A. Referring is the process of sending or guiding the patient to another source for assistance. Consultation is the process of inviting another professional to evaluate the patient and make recommendations to you about his or her treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of patient data to others.

The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to A. discuss the plan with the patient B. get physician orders to implement the plan C. set goals for the patient D. document the plan on the cardex for all to utilize

A. is correct. Step six is to confirm the diagnosis. If the cue cluster data do meet the defining characteristics, the diagnosis should be verified with the client and other health care professionals who are caring for the client. Tell the client what you perceive the diagnosis to be.

A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The student needs further explanation when making which statement? A. It is important to look closely at cultural norms." B. All patients have the same defining characteristics." C. It is essential to look at all patient responses accurately." D. "Labels for specific diagnoses do not always accurately describe diverse patient responses."

B is correct

The nurse is walking by a client's room and notices the client's pulse oximeter reads 89% on the monitor. What is the nurse's best action? A.Document the oxygen saturation level in the client's medical record. B.Enter the room and auscultate the client's lung sounds. C. Notify the healthcare provider immediately of the finding. D. Administer the scheduled diuretic as prescribed.

B. Assessment is always the first. The client's oxygen saturation level is low. Urgent situations warrant immediated assessment and intervention. The nurse should assess first to determine the need for interventions such as diuretic administration. The nurse then may need to contact the healthcare provider. After the client has been cared for, the nurse should document the situation.

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission?入院时最可能遗漏的预防措施是什么 A. SBAR communication B. Medication reconciliation C. High-alert labeling D. Client teaching of side effects

B. Medication reconciliation is a preventive measure to ensure the continuity of care for a client and the continuation of medications taken at home that are necessary for the client's well being. SBAR is a communication tool to ensure appropriate information is given to the healthcare provider to care for the client. High-alert labeling is utilized to identify many sound alike medications. The teaching of side effects is crucial to informed care, yet is not the most likely cause of omission of medication from home.

A nurse is working with a patient who has a history of chronic obstructive pulmonary disease (COPD). While bathing the patient, the nurse senses that something is not quite right and takes the patient's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following? A. knowledge B. intuition直觉 C. scientific rationale D. prior history

B. The nurse is acting on intuition, in this case, the feeling that something is not quite right. Scientific rationale is an explanation based on science. Knowledge is based on science and theories that the nurse learned in school. Prior history of the patient is not what the nurse is acting upon in this case.

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information? A. Collaborative problem B.Risk diagnosis C. Wellness diagnosis D. Referral to dietitian

C.

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan? A. Discuss the plan of care with all of the health care providers involved. B. Share the assessment and plan with the client's primary health care provider. C. Ask the client for opinions and willingness to proceed with the interventions. D. Identify the needs of the client's family in relation to the priority problem.

C. The plan of care should be agreeable to the patient. Before finalizing the plan, it is important for the nurse to share the information with the patient and seek out opinions and willingness to proceed with the interventions. Although discussing the plan of care with the all health care providers involved, involving the client in the process is the only way to know if the goals are realistic for his unique needs. Sharing the assessment and plan of care with the client's primary health care provider will only be necessary once the client has voiced his opinion and willingness to proceed with the interventions. The client's family should be involved in the plan of care and likely serve to make it more effective. The client must agree first and demonstrate willingness prior to discussing it with the family.

The nursing instructor informs the students that they should obtain a North American Nursing Diagnosis Association reference book. What would the purpose of obtaining this reference be? (Select all that apply) A.Assist with understand medical-surgical interventions. B. Apply standard nursing diagnosis to fit all patients. C. Helps select valid diagnosis. D. Determine when and when not to use each nursing diagnostic category. E. Helps to rule out invalid diagnosis.

CDE Reference texts such as NANDA Nursing Diagnoses: Definitions and Classifications can assist the nurse to determine when and when not to use each nursing diagnostic category. It assists with ruling out invalid diagnoses and selecting valid diagnoses. Both the definition and defining characteristics should be compared with the client's set of data to make sure that the correct diagnoses are chosen for the client.

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse? A. Have the UAP retake the blood pressure B. Notify the physician C. Recheck blood pressure in 30 minutes D. Reassess blood pressure

D is correct recheck the data is more important in validation.

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? A. Clustering together unrelated cues B. Diagnosing a client without hypothesizing several diagnoses C. Incorrectly wording a diagnostic statement D. Overlooking consideration of the client's cultural background

D. overlooking 忽视

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. A. knowledge B. experience C. time D. practice E. seeing things as only right or wrong

E CORRECT, Beginning nurses tend to see things as right or wrong, whereas experts realize there are shades of gray or areas between right and wrong. Novices also tend to focus on details and may miss the big picture, whereas experts have a broader perspective in examining situations.