NURS 221 Clinical Judgement

a nurse asks a client to rate their current level of pain using a scale of 0-10 after admin pain med 30 mins ago. Which of the following steps of the nursing process is the nurse performing? A. Evaluation B. Implementation C. Analysis D. Planning

A. Evaluation A nurse in this situation is using the evaluation step of the nursing process by collecting subjective data from the client using an established pain scale to compare the clients current pain level to their original pain level

Name the steps of the nursing process

Assessment, Analysis, planning, implementation, evaluation

what should the nurse do during the evaluation step of the nursing process? A. set the time frame for goals B. revise a plan of care C. determine priorities D. establish outcomes

B

A patient became short of breath and reported sudden chest pain while being transferred from the bed to a chair for the first time after surgery for a fractured hip. The nurse immediately returned the patient to bed, raised the head of the bed and started oxygen at 2 L via nasal cannula. Which step of the nursing process was most important in this scenario? A. Planning B. Assessing C. Evaluating D. Diagnosing

C. Evaluating Explanation: The nurse's actions were based on an evaluation of the patient's response to the nursing care being delivered. The reassessment of the patient and comparing the actual outcome to desired outcome is considered evaluation.

A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process A. Evaluation B. Implementation C. Analysis D. planning

D. Planning In the planning step of the nursing process, the nurse develops interventions to treat or manage the client's identified problems. The plan of care guides the treatment of the client and should be modified as the client's condition changes. In this scenario, the nurse is making goals for the client regarding ambulation.

Name the six cognitive skills needed to make appropriate clinical judgments

Recognizing Cues , Analyzing Cues, Prioritizing Hypotheses , Generating Solutions, Taking Action, Evaluating Outcomes

True or False. Critical thinking is the foundation for clincial decision making

True

describe the analysis

amalyze assessment data, determine actual or potenatial diagnoses, problems, and issues

Describe the assessment

collect data (subjective and objective) and information, relatuve to healthcare consumers health and situation

What is the clinical judgement model

combo of nursing knowledge and skills. It is utalized for info about a situation, recognize relevant findings, analyze and make inferences, and initiate appropriate interventions to support the quality, safe, client care that leads to optimal outcomes

describe implementation

coordinate care delivery, strategies to promote health and safe enviroment

describe planning

develop a plan or goal, prescribe strategies to attain expected measureable actions

describe evaluation

evaluate progress toward attainment of outcomes

describe prioritizing hypotheses

nurses prioritize what can harm/ benefit the patient best for their specifc care

describe generating solutions

nurses use prioritized hypotheses to identify expected outcomes, how can this patient not experinece pain anymore or how can I as the nurse ensure the patient is eating or getting enough fluids

What is the clinical judgement

observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care

describe evaluating outcomes

when the nurse compares observations with expected outcomes. Looking at how the patinet is doing (improvement?) is there anything else I as the nurse could have done for the patient/ situation. How will patient actions affect outcome?

List the following nursing interventions in the order representing the steps of the nursing process beginning with the first step and progressing to the last step. 1. Obtaining a list of the patient's allergies. 2. Concluding that a patient has a deficient fluid volume. 3. Administering a prescribed enema to a patient who is constipated. 4. Assessing a patient's level of pain after administering an opioid analgesic. 5. Identify nursing interventions that should be implemented to meets a patient's needs.

1, 2, 5, 3, 4 Explanation: 1. Collecting data from the patient is a form of assessment. Assessment is the first step of the nursing process. 2. Coming to a conclusion about collected data is part of the analysis step of the nursing process. Analysis is the second step of the nursing process. 5. Identifying nursing interventions that should be implemented is related to the planning step of the nursing process. Planning is the third step of the nursing process. 3. Administering an enema is the performance of a procedure. Procedures that require direct patient care are part of the implementation step of the nursing process. Implementation is the fourth step of the nursing process. 4. Determining a patient's response to a medication is part of the evaluation step of the nursing process. Evaluation of care is the fifth step of the nursing process.

Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.) 1. Recognize normal changes associated with aging. 2. Avoid direct eye contact. 3. Lean forward and smile as you pose questions. 4. Allow for pauses as patient tells his story. 5. Use the list of questions from the clinic assessment form to complete all data.

1,3,4

A nurse enters a patient's room at the beginning of a shift to conduct an assessment of his condition following a blood transfusion. The nurse cared for the patient on the previous day as well. The patient has a number of issues he wishes to share with the nurse, who takes time to explore each issue. The nurse also assesses the patient and finds no signs or symptoms of a reaction to the blood product. The nurse observed the patient the prior day and sees a change in his behavior, a reluctance to get out of bed and ambulate. Which of the following actions improve the nurse's ability to make clinical decisions about this patient? (Select all that apply.) 1. Working the same shift each day 2. Spending time during the patient assessment 3. Knowing the early mobility protocol guidelines 4. Caring for the patient on consecutive days. 5. Knowing the pattern of patient behavior about ambulation

2,4,5

A nurse is assessing a 15-year-old female patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: a. Clinical judgment b. Clinical reasoning c. Critical thinking d. Blended competencies

A Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical/legal skills combined with the willingness to use them creatively and critically when working with patients.

Which action is associated with the evaluation step of the nursing process? A. A nurse takes the vital signs when a patient reports chest pain. B. A nurse determines that a patient is at risk for impaired skin integrity because of reduced mobility and malnutrition. C. A nurse and patient decide that within 3 days the patient will learn how to draw up and self-administer insulin safely. D. A nurse determines that further intervention is necessary when the patient experiences sacral edema after being turned and positioned every 2 hours.

D Explanation: Revising a plan of care in response to a patient not achieving a desired outcome (absence of signs and symptoms of pressure when turning and positioning a patient every 2 hours) is part of the evaluation step of the nursing process.

A nurse at an urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using? A. Evaluation B. Implementation C. Analysis D. Assessment

D. Assessment The nurse should identify auscultating a client's lungs as being part of the assessment step of the nursing process because the nurse is collecting data from the client. Auscultating the client's lung sounds is part of a physical assessment.

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. a. The nurse uses critical thinking skills to plan care for a patient. b. The nurse correctly administers IV saline to a patient who is dehydrated. c. The nurse assists a patient to fill out an informed consent form. d. The nurse learns the correct dosages for patient pain medications. e. The nurse comforts a mother whose baby was born with Down syndrome. f. The nurse uses the proper procedure to catheterize a female patient.

a, d Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.

describe analyzing cues

when the nurse develops a hypotheses and determines data still needed for patient

describe taking action

when the nurse performs an action for solutions to address highest priorities which could be an intervention or an assessment

describe recognizing cues

when the nurse reviews relevant client data and determines what they mean. To notice any consistencys