Fundamentals Chapter 5: Critical Thinking and Clinical Judgment

Which question asked by the nurse demonstrates proper understanding of a functional assessment?

"Can you bathe and dress yourself?"

The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process?

Diagnosis

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

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing

Which statement made by the nurse indicates data that would be documented as part of an objective assessment?

"The client's right leg is cold to the touch, from the knee to the foot."

The nurse is caring for a client who has left-sided weakness due to a recent cerebrovascular accident (CVA). The client has been admitted to the hospital for a urinary tract infection and has been experiencing urinary incontinence. The client prefers to walk without mobility aids. When preparing the client's nursing care plan, which actual and potential problem(s) will the nurse include? Select all that apply. 1. altered urinary elimination due to urinary tract infection as evidenced by urinating in bed and while ambulating 2. falls risk related to left-sided weakness and ambulating without mobility aids 3. pyelonephritis risk related to urinary tract infection 4. noncompliance with use of ambulatory aids to assist with walking 5. altered sleep pattern risk related to urinary urgency and frequency

1, 2, 5

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. 1. heart failure 2. pneumonia 3. . altered mobility 4. altered nutrition 5. ineffective coping

3, 4, 5

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. 1. heart failure 2. pneumonia 3. altered mobility 4. altered nutrition 5. ineffective coping

3, 4, 5

Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)?

A client report of shooting pain up the left leg

A nursing student is practicing to develop critical thinking skills specifically in the area of theoretical knowledge. With which activity would the student most likely be involved? 1. assessment 2. diagnosis 3. planning 4. implementation 5. evaluation

All

What nursing organization first legitimized the use of the nursing process?

American Nurses Association

A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client?

Asking whether the client feels less anxious 30 minutes after administering the medicine

A 15-year-old adolescent confides in the nurse that he or she is considering sexual activity with a partner. The client asks the nurse what the best method of birth control is for someone this age. Before answering, the nurse hopes to discover more about what the client knows about sexual activity and birth control. This is an example of which phase 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

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking?

Clarity

The nurse is caring for a client in a critical care unit. The client's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm?

Cognitive and technical skills

The nurse uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill?

Cognitive skill

What is a systematic way to form and shape one's thinking?

Critical thinking

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective

A hospital client has an aggressive fungal infection in the right eye that necessitates evisceration (removal of the eye). Consequently, the client requires twice-daily packing and dressing changes to the orbit. Which of the nurse's actions in the care of this client most clearly demonstrates interpersonal skills?

Ensuring the client's privacy during dressing changes and providing an explanation during the procedure

A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the client's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is 3 hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which type of skills?

Ethical/legal skills

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking.

The client is admitted with multiple injuries, including a head injury, fractured ribs, and hypoventilation. Vital signs are: BP 110/84, T. 98.8/37.1, P. 88, Resp. 28. Which is the client care priority?

Maintain an open airway.

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?

Nursing process

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case?

Obtaining data regarding the amount and frequency of drinking

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

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process

After completing an assessment of a client, which finding should the nurse determine is the priority for care?

Severe bleeding from a wound

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client.

A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which aspect of the nurse's execution of this order demonstrates technical skill?

Starting a new, large-gauge intravenous site on the client and priming the infusion tubing

A nurse has gathered data through interview, observation, and physical assessment of a client and has formulated diagnostic statements. What would the nurse do during the outcome identification phase?

formulate client-focused goals

A client presents to the emergency room reporting weight gain, respiratory crackles, productive cough, and shortness of breath. The nurse demonstrates the implementation phase of the nursing process by performing which action?

inserting a peripheral IV and urinary catheter

A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified:

outcome

Which interpersonal skill is essential to the practice of nursing?

promoting the dignity and respect of clients as people

Critical thinking is important in making an effective nursing judgment. Which technique would be most effective for the nursing student to adopt to improve classroom success?

turn errors into learning opportunities

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:

uses critical thinking to direct care for the individual client.