Nursing Process and Critical Thinking

The registered nurse is educating a graduate nurse about critical thinking when caring for clients. Which action made by the graduate nurse indicates the use of critical thinking?

Analyzing a client's temperature changes and assessing for signs of infection

The nurse enters a client's room to obtain a fasting blood glucose reading and notices the breakfast tray is in front of the client. Which action best indicates the nurse using critical thinking?

Asking the client if he or she has eaten any food yet

Which complex thinking process is logical thinking that connects thoughts to create meaning?

Clinical reasoning- Nurses use logical thinking to connect facts to formulate a plan of care. This is clinical reasoning.

A client who undergoes a lung biopsy has a potential complication of a pneumothorax. When creating the nursing diagnosis for a client undergoing a lung biopsy, which type of problem is this particular type of complication?

Collaborative problem

Which describes the central source of information needed to guide holistic, goal-oriented care to address the client's unique needs?

Comprehensive nursing care plan The comprehensive nursing care plan is used as a guide to address the client's unique needs and establish goals.

Which information is needed to record an evaluative statement?

Conclusion and supportive data

A nurse performs an admission assessment on a client who is admitted with pneumonia. The nurse then creates an outcome-based, interdisciplinary plan that sequences care and expectations for clients with pneumonia. What do these actions describe?

Critical pathway

How are critical-thinking skills used when following hydration recommendations for two different clients with dehydration issues, one due to a gastrointestinal virus and one with kidney dysfunction?

Decisions are geared toward individual differences.

Which concepts are involved in full-spectrum nursing?

Doing Caring Thinking Client Situation

A research-based method for judging and choosing nursing interventions is referred to as what?

Evidence-based practice

Which statement best reflects a critical-thinking philosophy being taught to a nursing student?

"Think about different interventions that can be used with this client."

Which are examples of client uniqueness that could cause challenges or differences in care and must be considered when creating a nursing plan?

-A single mother recovering from a fall at work -An elderly Native-American admitted for malignant hypertension -A client living below the poverty line, admitted with pneumonia

A postsurgical client has a new nursing diagnosis of "Constipation related to immobility and decreased gastrointestinal (GI) motility secondary to narcotic analgesics." Which are appropriate nursing interventions for this client? Select

1. Administer laxative or stool softener as prescribed. 2. Encourage increased fluid intake, including warm liquids. 3. Educate the client about and encourage a high-fiber diet.

What does the nurse know is true about conducting the nursing assessment? Select All That Apply.

1. Assessments must be completed within 24 hours of inpatient admission. 2. Assessment cannot be delegated to others. 3. All clients are assessed for pain, nutritional status, and risk for falls.

Which type of data should be included in the discharge planning?

1. Functional and self-care limitations 2. Emotional stability and ability to learn 3. Family or other caregivers available 4. Use of community services before admission

Which are tools for recording assessment data?

1. Graphic flow sheet 2. Intake and output sheet

Which are examples of cue clusters for a nursing diagnosis? Select All That Apply.

1. Hard, painful bowel movement approximately every 3 to 4 days; sedentary lifestyle; low dietary fiber intake; dry skin 2. Pain and limited range of motion in knees, use of walker, medical diagnosis of osteoarthritis 5. Urinary incontinence, lower abdominal pain, bladder spasm

Which scenarios are considered collaborative problems?

1. Hyperglycemia with type 2 diabetes 2. Infection in a postsurgical client 3. Hemorrhage in a postpartum client

How is critical-thinking used in nursing other than in the nursing process?

1. In determining how many nurses to staff during a shift 2. When creating a list of inventory needed for the unit

A registered nurse is instructing nursing students about incorporating critical thinking into client care. Which attributes will the registered nurse include during this lesson?

1. Need to find the truth 2. Openness to other options 3. Use of reasoned thinking 4. Capacity to reflect on situations

Which are examples of nursing diagnoses? Select All That Apply.

1. Risk for impaired skin/tissue integrity 2. Ineffective impulse control 3. Insufficient breast milk

The nurse is assigned to a client who experiences major depression and anxiety. Which steps are part of the planning stage of the nursing process?

1. Stating that the client will report feeling less distress at social gatherings 2. Selecting the best antidepressant for the client 3. Recommending a cognitive behavioral therapist for the client

The nurse is assigned to care for a client who reports nausea, vomiting, and diarrhea. The client's vital signs are as follows: T 100.6°F, AP 100, RR 20, BP 92/69, O2 saturation 98%. Which nursing actions represent the nurse using critical-thinking skills to separate important from unimportant data?

1. The nurse asks what the client has eaten in the past 24 hours. 3. The nurse asks the client how long the symptoms have been present. 4. The nurse assesses the skin turgor of the client.

When arriving to take a client's blood pressure, a nurse witnesses an argument between the client and spouse. Recognizing that stress can alter blood pressure, the nurse encourages the spouse to step out and get something to drink, giving the client an opportunity to calm down. The nurse returns later to take the client's blood pressure after the client has had time to settle down. What is true about this situation?

1. The nurse used theoretical knowledge by recognizing the argument would raise blood pressure. 2. The nurse used ethical knowledge by returning to get an accurate reading instead of just assuming it would return to normal. 3. The nurse used practical knowledge by communicating with the spouse and suggesting a break in order to get an accurate reading.

Which characteristics apply to the nursing process

2. Actions occurring simultaneously 3. Involves both thinking and doing 5.Goal-directed and client-centered

Which is the best example of intellectual courage?

A nurse fairly examines his or her own values and beliefs even when uncomfortable.

Which statement best describes a nursing diagnosis?

A nursing diagnosis involves the identification of the client's strengths and needs based on assessment data.

According to Maslow's Hierarchy of Needs, what is the appropriate order of priority of the client needs?

Adequate hydration Falls prevention Support group Medication teaching A vase of flowers

The abbreviations "AEB" and "AMB" are considered connecting phrases for which portion of the nursing plan?

Basic three-part statement

A nurse becomes irritated with a client who is requesting more ice chips and refers to the client as "the ice man in 201" to other nursing staff. In which important component of nursing has the nurse failed to engage?

Caring

Which is an appropriate goal statement for a postpartum female client with a nursing diagnosis of "lower abdominal pain r/t uterine contractions and hyperextension of cervix"?

Client will verbalize reduced pain with pain management interventions to a satisfactory level within a 12-hour period

A client is processing information regarding a new diagnosis and the treatment the physician has recommended. The client's family has provided excessive input and are attempting to have the nurse "convince" the client to see things their way. Which critical-thinking attitude should the nurse present?

Fair-mindedness

Which are considered critical-thinking attitudes?

Fair-mindedness Independent thinking Intellectual curiosity

A nurse has multiple clients assigned at the beginning of a shift on the surgical unit. Which client should be assessed first?

Female, posthysterectomy, blood pressure 90/52 mm Hg

. A nurse is working in a health-care facility with a protocol of having clients who have pneumonia turn, cough, and deep breathe. This nurse is assigned to care for a client admitted with pneumonia but does not encourage the client to cough because the client also has esophageal varices from cirrhosis. Which aspect of critical thinking is this nurse using to guide client care?

Individual differences- Clients may have comorbidities that prevent the nurse from following evidence-based practice. Esophageal varices from cirrhosis contraindicate coughing to clear secretions because this could cause a massive upper gastrointestinal bleed. The nurse is using critical thinking and taking into account the individual differences of this client.

Using Maslow's hierarchy of needs, place the nursing diagnoses in order of priority.

Ineffective airway clearance Ineffective breathing pattern Deficient fluid volume Risk for fall Wandering Impaired memory

When creating a nursing diagnosis for a client with renal failure, what questions should the nurse ask during the assessment process?

Is the client still producing urine? What is the client's oral intake? Does the client exhibit signs of edema? Can the client engage in activities of daily living?

Which are components of caring?

Knowing Being with Enabling Maintaining belief

The nurse documents, "Anxiety related to change in health status and situational crisis."

Nursing diagnosis

Which nursing action is part of the evaluation phase when performing wound care for a client?

Obtaining wound measurements once a week

Which type of evaluation is performed while implementing care, immediately after an intervention, and at each client contact?

Ongoing evaluation- Ongoing evaluation is performed frequently, as part of client assessment, and while implementing care.

Which nursing interventions are considered direct-care interventions?

Physical care Emotional support Client education

In a client's health record, the nurse documents, "Nutritional status will improve as evidenced by a weight gain of 3 lb (1.4 kg) by July 1." This statement is an example of which step of the nursing process?

Planning

In which scenario is the nurse using self-knowledge when providing client care?

Questioning oneself after performing cardiopulmonary resuscitation on a client who developed cardiac arrest

A nurse is in charge of a client with multiple challenges who is not responding to care as predicted. Upon evaluating the care plan and outcomes the nurse realizes the interventions should be altered. What is the next step in the nursing process?

Reassess the client, create a new nursing diagnosis if needed, and plan for new outcomes with new interventions.

The scientific basis for client care is ever-changing. What can a nurse do to stay current with this multifaceted information?

Refine critical-thinking skills as well as update knowledge and skills frequently.

Which credible sources of information should the nurse use to obtain information about the client when developing a plan of care?

Spouse Electric Medical Record Nursing Diagnosis

The nurse in a community clinic is assessing a 23-year-old client who reports upper respiratory congestion and a cough that has lingered for 3 weeks. In the initial interview, the nurse learns the client's family lives out of state and that the client goes to school part-time while waiting tables part-time. What might the nurse infer from this information?

The client has most likely not had a recent physical examination.

Which is a valid goal statement for measuring and managing pain?

The client will report pain greater than level 4 to the nurse.

Which is an example of a nurse using subjective data to clarify objective data?

The nurse notes the client has a rash and asks the client if the rash is itching.

A client is admitted for a hip fracture following a fall at home. The client has surgery to repair the fracture and is getting ready for discharge. The client is using a walker to ambulate and working with physical therapy. Which is an important consideration for this client for discharge planning?

The safety and physical layout of the home environment

The nurse is developing a plan of care for a client admitted with dehydration from the flu. Which documentation in the electronic health record is based on theoretical knowledge?

The social worker states the client is in Erickson's stage of ego integrity versus despair.

A statement such as "readiness for enhanced self-care" is an example of which type of nursing diagnosis?

Wellness diagnosis