HA PrepU Chapter 2- Critical Thinking in HA

Considering the acronym OLD CART, the nurse is asking a newly admitted patient questions during the assessment process. The patient is a 35-year-old man who presents with pain in the upper arm since lifting weights 3 days ago. What question would be appropriate to ask that would give information for the "D" in the acronym? "Does the pain come and go or is it constant?" "Has anything helped relieve the pain?" "Can you point to where the pain is located?" "Is there anything that makes the pain worse

"Does the pain come and go or is it constant?" The "D" in OLD CART represents duration of the symptom. Asking if the pain comes and goes provides an answer to that question.

A client presents to the clinic with reports of an itchy rash all over the body. The nurse observes lesions on the client's arms and legs as well as the presence of a dry, hacky cough and sneezing. Which data collected from the client can be classified as a subjective abnormal finding? Presence of rash Dry, hacky cough Continuous sneezing Itchy feeling

Itchy feeling

A client comes to the health care facility with reports of abnormal bleeding from his gums, chills, and recurrent infection. How should the nurse cluster the data collected from the client? Check for defining characteristics for the clustered data Look for related cues in the abnormal findings and strengths Hypothesize and generate possible nursing diagnoses Verify the cue data with the client and other health care professionals

Look for related cues in the abnormal findings and strength

Which of the following events during the assessment process most indicates a need for validation? An apparently healthy client exhibits an abdominal scar suggestive of an open appendectomy in the past. A client begins crying as he tells the examiner about the numerous stressors in his life. A client complaining of flu-like symptoms has an oral temperature of 38.4°C. The client denies feeling upset or anxious about her recent cancer diagnosis but fidgets throughout the interview and assessment.

The client denies feeling upset or anxious about her recent cancer diagnosis but fidgets throughout the interview and assessment.

Which characteristics of critical thinking should a nurse employ when analyzing data collected during the physical assessment of a client? Select all that apply Use rationale to support opinions and decisions Reflect on thoughts before reaching a conclusion Reflect on whether the data collected is sufficient for diagnosis Use past clinical experience to build knowledge Reflect if the data collected is valid and relevant

Use rationale to support opinions and decisions Reflect on thoughts before reaching a conclusion Use past clinical experience to build knowledge reflecting on whether the data collected is sufficient for diagnosis and is valid and relevant are two of the pitfalls the nurse should avoid at the assessment stage.

A client asks why a nurse measured the blood pressure after the nursing assistant completed the measurement a few minutes ago. What should the nurse respond to the client? a. "It was done to validate the reading." b. "The first reading was measured too early." c. "The nursing assistant had difficulty with the reading." d. "The second reading was used as a guide for providing a medication."

a. "It was done to validate the reading." The second reading was to verify the data with another health care professional. A blood pressure measurement is not done "too early." Saying that the nursing assistant had difficulty with the reading could cause the client to be alarmed or to question the nursing assistant's ability to provide care. Some medication may require a blood pressure measurement however this is unlikely considering the timing of the measurements.

A nurse has admitted a client to the medical unit who has just been diagnosed with endocarditis secondary to IV drug use. The nurse has completed the collection of objective and subjective data. What question should guide the next step in the nurse's data analysis? a. "What are this client's strengths?" b. "What is this client's prognosis?" c. "Why does this client use opioids?" d."What are this client's hopes for the future?"

a. "What are this client's strengths?" The first step of the data analysis process is the identification of abnormal data and strengths. None of the other listed questions directly addresses this step in the process.

Which of the following would be included as the primary purpose of assessing a client's health status? a. Analyze subjective and objective data b. Confirm or rule out a diagnosis c. Formulate a nursing diagnosis d. Check for the presence of defining characteristics

a. Analyze subjective and objective data The primary purpose of assessing a client's health status is to analyze the subjective and objective data collected. From there, nursing diagnosis can be proposed and confirmed or ruled out based on the presence of defining characteristics

A novice nurse is struggling with making accurate nursing diagnoses. The supervisor, a much more experienced nurse, counsels the novice on what characteristics help nurses make better diagnoses. Which of the following should the supervisor mention? Select all that apply. a. Awareness of when exceptions apply to rules b. A view of things as being either right or wrong c. A focus on the big picture d. Years of experience e. A focus on the details f. Seeing shades of gray when making decisions

a. Awareness of when exceptions apply to rules c. A focus on the big picture d. Years of experience f. Seeing shades of gray when making decision

As a beginning nurse, how can abnormal assessment findings best be evaluated for the need for further investigation? (Select all that apply.) a. Look for trends in declining status. b. Consult with other healthcare providers. c. Review diagnostic test results. d. Ask for a more experienced nurse's opinion. e. Adapt nursing interventions based on intuition.

a. Look for trends in declining status. b. Consult with other healthcare providers. c. Review diagnostic test results. d. Ask for a more experienced nurse's opinion. The beginning nurse usually has not yet developed a keen sense of nursing intuition.

A nurse is providing care for a client who has chronic type 2 diabetes. In recent days, the client's blood glucose levels have been higher and more volatile than usual. After drawing this inference, the nurse should take what action? a. Make appropriate referrals b. Assess the client more frequently c. Document the medical diagnosis of hyperglycemia d. Beginning collecting subjective data

a. Make appropriate referrals Another purpose of step three in the data analysis process is the referral of identified problems for which the nurse cannot prescribe definitive treatment. Blood sugar management often falls into this category. The nurse cannot make medical diagnoses and more frequent assessment does not fully provide what the client needs.

When constructing a nursing care plan, what should you reference? (Mark all that apply.) a. Therapy b. Healthy People 2020 health indicators c. Patient education d.Input from the patient's physician e. Diagnosis

a. Therapy c. Patient education e. Diagnosis

Essential characteristics for the development of critical thinking skills include all the following except: a. Keeping an open mind b. Following instructions c. Using evidence to guide decisions d. Considering past experiences to plan appropriate actions

b. Following instructions

In what area do nurses use formalized screening and assessment tools? a. Vital signs b. Skin breakdown c. Hand hygiene d. Kidney failure

b. Skin breakdown Nurses utilize many assessment tools. These tools are used in areas of prevention such as falls, malnutrition, and skin breakdown.

The preceptor believes a new graduate nurse is improving in critical thinking skills. What did the preceptor assess to make this decision about the graduate's behavior? Select all that apply. a.Uses textbooks to research issues b.Uses rationales to support decisions c.Is aware of the interaction of others d.Uses past situations to build knowledge e.Reflects on thoughts before making a conclusion

b.Uses rationales to support decisions c.Is aware of the interaction of others d.Uses past situations to build knowledge e.Reflects on thoughts before making a conclusion

How does an experienced nurse improve his or her efficiency and enhance the relevance and value of the data he or she collects? a. By conducting the assessment as rapidly as possible b. By utilizing an information source other than the patient c. By correlating medical diagnoses and nursing diagnoses d. By generating plans early

d. By generating plans early By generating plans early and testing them sequentially, experienced nurses improve their efficiency and enhance the relevance and value of the data they collect.

After completing an assessment the nurse recognizes that a client is at risk for cardiovascular disease. Which critical thinking step is this nurse completing? clustering the data interpreting the findings identifying abnormal data proposing nursing diagnoses

identifying abnormal data