PrepU Ch 13
Which activity is the clearest example of the evaluation step in the nursing process? A) Checking the client's blood pressure 30 minutes after administering captopril B) Taking a client's blood pressure on both arms at the beginning of a shift C) Recognizing that the client's blood pressure of 172/101 is an abnormal finding D) Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading
A) Checking the client's blood pressure 30 minutes after administering captopril
Which statement regarding critical thinking in nursing is true? A) It is a systematic way of thinking. B) It shows trends and patterns in client status. C) It makes judgments based on conjecture. D) It supplies validation for reimbursement.
A) It is a systematic way of thinking Critical thinking is a systematic way of thinking that involves purposeful, outcome-directed thinking. Critical thinking makes judgments based on evidence rather than conjecture. Providing a foundation for evaluation and quality improvement, showing trends and patterns in client status, and supplying validation for reimbursement are functions served by documentation.
Put the phases of the nursing process in the correct order
Assessment Diagnosis Planning Implementing Evaluation
The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? A)Administer a prescribed medication to decrease the client's blood glucose level. B)Analyze the data and create an individualized nursing diagnosis. C)Follow up with the client later to determine whether the client's laboratory test results improve. D) Identify outcomes for the client with the client's input.
B) Analyze the data and create an individualized nursing diagnosis. The second part of the nursing process is the analysis of data that can help determine nursing diagnoses. Because the nurse has the assessment findings of polydipsia, polyphagia, polyuria, and an increased HgbA1C level, the nurse can analzye these findings to help to determine the most appropriate nursing diagnosis. Once the nursing diagnosis is determined, then the nurse, with input from the client, can identify outcomes and interventions, such as medication administration, implement the interventions and evaluate them.
A nurse is providing care to an older adult client diagnosed with heart disease. The nurse uses the nursing process to provide individualized care using the actions listed below. Place the actions in the order that the nurse would most likely complete them using the nursing process. 1 obtains the client's vital signs 2 identifies risk for fluid volume excess 3 develops a realistic goal for monitoring fluid balance 4 prepares an individualized strategy for addressing risk 5 obtains the client's weight daily 6 determines that the client's fluid balance is stabilized
1.obtains the client's vital signs 2.identifies risk for fluid volume excess 3.develops a realistic goal for monitoring fluid balance 4.prepares an individualized strategy for addressing risk 5.obtains the client's weight daily 6.determines that the client's fluid balance is stabilized
The nurse is providing education to a group of middle school students regarding cold weather safety. One of the students asks the nurse how cold her body will get when it is cold outside waiting for the school bus. The nurse responds: A) "We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time." B) "You can expect your body temperature to drop about 3 degrees during your time at the bus stop." C) "When exposed to extreme cold, the body works hard to stay warm and may warm itself 1-2 degrees above normal during exposure." D) "Everyone is different so I cannot say how your body might react."
A) "We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time." Humans are warm-blooded creatures, which means they maintain a consistent internal body temperature independent of the outside environment. The body's surface or skin temperature can vary widely with environmental conditions and physical activity. Despite these fluctuations, the temperature inside the body, the core temperature, remains relatively constant, unless the patient develops a febrile illness.
The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? A) Activity and rest B) Health promotion C) Nutrition D) Self-perception
A) Activity and rest A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertient for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.
The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client? A) Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats B) Administer a daily multivitamin C) Monitor for allergies D) Weigh client as needed
A) Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats Because this client is underweight and has an allergy to wheat, rye, and oats, administering a diet with 2,500 calories (10,460 kJ) and no wheat, rye, and oats would be the most appropriate intervention to meet the specific needs of this client. Administering a multivitamin, monitoring for allergies, and weighing the client as needed are generalized nursing measures and not specific to this client.
The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the most appropriate nursing action? A)Assess the client's back visually. B)Document the rash in the client's chart. C)Establish a nursing diagnosis of Altered Skin Integrity. D)Report it to the health care provider.
A) Assess client's back visually Assessment is the first phase in the nursing process, so the nurse should perform a visual assessment of the client's rash before proceeding to activities that pertain to later phases, such as reporting or documenting the rash or formulating a nursing diagnosis.
A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process? A) Assessment B) Diagnosis C)Planning D) Implementation
A) Assessment During assessment, the nurse recognizes the existence of cues and conducts a focused data collection. During diagnosis, the nurse clusters cues, interprets the clusters, and validates the diagnoses for accuracy. Planning involves preparing a client plan of care, which directs the activities of the nursing staff in the provision of care. Implementation is the action phase of the nursing process.
The nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process? A) Assessment B) Planning C) Implementation D) Evaluation
A) Assessment The nursing process is a systematic method used by the nurse and client. Assessment is the first step to determine the needs for client care. Next is planning, which is based on the assessment obtained. Implementation is delivering the nursing interventions developed. Evaluation is reviewing the interventions and whether the goals that were developed in the planning stage were met.
A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation? A) Assisting the client to sit up in a chair B) Assessing the abdominal incision C) Monitoring vital signs D) Notifying the health care provider of lab results
A) Assisting client to sit up in a chair Caring skills are nursing interventions that restore or maintain a person's health and may involve actions as simple as assisting with activities of daily living--the acts that people normally do every day, such as bathing, grooming, dressing, toileting, and eating. Assisting the client to sit up in the chair is an example of this type of caring behavior. The other options are important nursing tasks, but they are not demonstrating the art of caring.
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? A) Clarity B) Accuracy C) Precision D) Relevance
A) Clarity The nurse's question reflects clarity, or the need for more information. Accuracy would be reflected in questions about the information being true. Precision is reflected by questions asking for more details or specifics. Relevance would be reflected by questions related to how something connects to the issue.
A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented? A) Clinical reasoning B) Caring C) Reflection D) Assessment
A) Clinical reasoning Clinical reasoning is the process of making a nursing judgment that will provide safe and quality care. Caring is holistically meeting the needs of the client. Reflection is looking back on events that have occurred and learning from them how to improve one's practice. Assessment is careful observation and evaluation of a client's health status.
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? A) Cognitive and technical skills B) Interpersonal and ethical skills C) Cognitive and ethical skills D) Interpersonal and technical skills
A) Cognitive and technical skills The nurse used cognitive and technical skills to interpret this cardiac rhythm. Cognitive and technical skills equip nurses to manage the clinical problems stemming from the client's changing health or illness state. Interpersonal and ethical skills are essential for concerns related to the client's broader well-being.
Which action exemplifies the purpose of evaluation in the nursing process? A) Decide whether to continue, modify, or terminate client care. B) Develop a prioritized list of nursing diagnoses. C) Develop an individualized plan of client care. D) Determine the client's health status, self-care ability, and need for nursing.
A) Decide whether to continue, modify, or terminate client care. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Outcome identification and planning specify the nursing diagnosis to the client's strengths, thereby individualizing the plan of care.
Which statement best conveys the role of intuition in nurses' problem solving? A) Intuition can be a clinically useful adjunct to logical problem solving. B) Intuition is an unreliable mode of thinking that should be avoided. C) In experienced nurses, intuition can be a valid replacement for scientific problem solving. D) Intuition is reliable when those nurses implementing it have a special "gift."
A) Intuition can be a clinically useful adjunct to logical problem solving. Creative, intuitive thinking can be useful supplements to more "in-the-box" methods of problem solving. While it should not be discouraged outright, it should also not be thought of as a replacement for logical or scientific problem solving. Intuition is not dependent on a special "gift" but is thought to be a product of experience and unconscious pattern recognition.
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? A) Planning; implementing B) Assessing; diagnosing C) Diagnosing; implementing D) Implementing; evaluation
A) Planning; implementing Determining the correct length of the NG tube to insert is an example of the planning that is necessary to conduct this nursing action. The actual insertion of the NG tube would constitute implementation. Assessment would be checking that after insertion, the NG tube is properly working. Diagnosing is gathering the evidence that the client needs an NG tube. Evaluation would be determining whether the outcome associated with inserting the NG tube has been accomplished.
What is the most beneficial use of the nursing process in addressing the needs of the client? A) Provides a universally applicable framework for nursing activities B) Allows the nurse to determine a medical diagnosis for the client C) Allows student nurses to work on assignments D) Targets desired outcomes for particular illnesses, procedures, or conditions
A) Provides a universally applicable framework for nursing activities The nursing process can be used with all clients, sick or well, of all ages and in all settings. The nursing process was not designed for use by students in their assignments. Critical pathways, not the nursing process, target desired outcomes for particular illnesses, procedures, or conditions. Medical diagnoses are determined by physicians.
The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis? A) Risk for falls B) Hypertension C) Congestive heart failure D) Pneumonia
A) Risk for falls Risk for falls is a nursing diagnosis. Hypertension, congestive heart failure, and pneumonia are medical diagnoses rather than nursing diagnoses.
Which statement is true of the nursing process? A) Scientific problem solving can occur within the nursing process. B) It is a valid alternative to using intuition to respond to nursing situations. C) It is more appropriate in medical surgical settings than community health care. D) Trial-and-error problem solving is incongruent with the nursing process.
A) Scientific problem solving can occur within the nursing process. Problem solving and the nursing process are not competing or mutually exclusive processes. Rather, scientific problem solving, trial-and-error, and intution may all take place within the nursing process. One of the strengths of the nursing process is that it is applicable to all nursing areas, from medical-surgical to community health settings.
The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as A) Supervisory B) Technical C) Surveillance D) Maintenance
A) Supervisory The term "supervisory intervention" is applied in the context of overseeing a client's overall care.
The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use? A) Trial-and-error problem solving B) Intuitive thinking C) Scientific problem solving D) Critical thinking
A) Trial-and-error problem solving The nurse is using trial-and-error problem solving. This type of problem solving involves testing any number of solutions until one that works for the problem is found. In this situation, the nurse attempts to obtain a blood pressure reading on three extremities before finally achieving success on the right leg; this required the nurse to test a number of locations. Intuitive thinking is a feeling (a sense) that doesn't use rational processes such as facts and data. Scientific problem solving is based on the scientific model. Critical thinking is the objective analysis of facts to form a judgment.
An obese client is in the clinic to start on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client? The client will: A) create an exercise plan that is realistic and valued. B) exercise every day for at least 30 minutes. C) only eat three meals per day. D) stop eating meat and walk every day after dinner.
A) create an exercise plan that is realistic and valued. Outcomes should be realistic and valued by the client and family. If this client creates an exercise plan that the client values and is realistic, then the client will be more likely to meet the outcome. Exercising every day, only eating three meals per day, or excluding meat from the diet may not be realistic or valued by the client who openly acknowledges liking to eat and does not like to exercise.
A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as: A) life-sized mannequins with a sophisticated computer interface. B) small, doll-like devices used for measuring vital signs. C) health care equipment that has practice modes. D) life-saving equipment that resuscitates clients in cardiac arrest.
A) life-sized mannequins with a sophisticated computer interface. The human client simulator, a life-sized mannequin with a sophisticated computer interface, presents students with clinical scenarios that evolve based on decisions that students make. The other equipment and devices described are tools used to learn and practice skills, rather than build on critical thinking skills.
Recording prioritized outcomes in the plan of care ensures which benefit? A) Each nurse can select which priorities to accomplish. B) Continuity of care can be provided to the client. C) The client will reach the goals of the care plan. D) The nurse knows what the client wants.
B) Continuity of care can be provided to the client. When outcomes are recorded and prioritized, each nurse can quickly determine priorities of care and the client benefits from continuity of care. The nurse may not pick and choose which priorities to accomplish, the plan does not ensure that the client will reach the goals, and the plan of care is more than the client's "wants."
Which step of the nursing process involves reporting or analysis of data to identify and define health problems? A) Assessment B) Diagnosis C) Planning D) Implementation
B) Diagnosis During the second phase of the nursing process (diagnosis), the nurse reports or analyzes data to identify and define health problems that independent or physician-prescribed nursing actions can prevent or solve. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care, performing interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments.
A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is most likely in which phase of the nursing process? A) Assessment B) Diagnosis C) Planning D) Implementation
B) Diagnosis The statement reflects a nursing diagnosis, which provides the basis for selecting interventions to achieve positive client outcomes. Assessment involves the collection of data. Planning involves preparing a client plan of care, which directs activities of the nursing staff in provision of client care. Implementation involves the actual initiation of the plan, evaluation of the response to the plan, and recording of nursing actions and client response to the actions.
A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment? A) Document that the client is talking back to the voices in the client's head. B) Document this assessment based on the client's behaviors. C) Do not document this assessment because the client could be using a wireless device to talk to family. D) Do not document this assessment because it is subjective.
B) Document this assessment based on the client's behaviors. Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs. Assessment should be documented accurately, completely, concisely, factually, and in a timely manner. To document factually, the nurse should document the client's behaviors, not the nurse's interpretation of the behaviors. In this situation, the nurse could and should quickly determine whether the client is using a wireless device to communicate with family and then document the client's behavior only if needed. The nurse's observation of the client talking out loud when no one else is in the room is an objective, not subjective, finding (the client reporting hearing voices in the head is an example of a subjective finding, as it is not observable by the nurse). In any case, both objective and subjective findings should be documented.
A client is admitted to the hospital with an abscess on the leg that will not heal after multiple treatment options as an outpatient. The nurse knows from past experiences that the appearance of this type of wound in clients heavily suggests a resistant bacterial infection and the need for contact isolation and intravenous antibiotics. The nurse begins to prepare for this admission. What type of problem solving does this exhibit? A) Experiential B) Intuitive C) Scientific D) Trial-and-error
B) Intuitive Intuitive problem solving occurs when an experienced person makes decisions or solves problems based on experiences that the person has had that share similarities or associations. Experiential is not a defined type of problem solving. Scientific problem solving requires a systematic approach using a seven-step process similar to the nursing process. Trial-and-error problem solving occurs when solutions are tested until one that solves the problem emerges.
The nurse enters the room of an adult client who reports postoperative abdominal pain. The client states that the pain is severe but is relieved some when getting up to go the bathroom. Which is the nurse's best determination based on this assessment? A) Even with pain, the client is ambulatory and therefore ready for discharge. B) More assessment would be beneficial to determine whether pain medication is desirable. C) The client's pain is really not that bad because the client can ambulate. D) The client should not be ambulating with pain.
B) More assessment would be beneficial to determine whether pain medication is desirable. Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs. More assessment is needed about this client's pain to determine the status and the need for intervention. There is not enough information to determine whether the client is ready for discharge. The health care provider should not question a client's report of pain. Clients may ambulate with pain.
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? A) Diagnosis B) Planning C) Implementation D) Evaluation
B) Planning During the planning phase, the nurse examines alternatives and judges the worth of evidence using this information to develop the plan of care for the client. During diagnosis, the nurse analyzes the assessment information to identify actual or potential responses to health problems. During implementation, the nurse carries out the plan of care. During evaluation, the nurse determines outcome attainment, revises plans, and identifies a client's perception of results.
The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action? A) During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. B) Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. C) After turning the client alone, the nurse realizes that the nurse should have insisted on having help. D) The nurse decides to turn the client every 4 hours because everyone is too busy to help.
B) Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. There are three types of reflection as defined by Schon: reflection-in-action, reflection-on-action, and reflection-for-action. Reflection-for-action is the desired outcome of the first two types and helps the person to think about how future actions might change as a result of the reflection. When the nurse realizes the need for help turning the client when first attempting to turn the client, this is reflection-in-action. When reflecting whether everyone is using appropriate resources, this is reflection-on-action. When adapting the client's plan of care based on these other reflections, this is reflection-for-action. Turning an obese client without assistance is unsafe and resources should be used. The client's outcomes should not be jeopardized by altering the plan of care due to the time constraints of staffing.
Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes? A) Memorization B) Reflection C) Assessment D)Evaluation
B) Reflection Reflection is defined as a purposeful activity that leads to action, improvement of practice, and better client outcomes. Memorization is strict learning of material for recall. Assessment is careful observation and evaluation of a client's health status. Evaluation is the assessment and review of the quality and suitability of the care given and the client's responses to that care.
What is the purpose of the diagnosis phase of the nursing process? A) To decide whether to continue, modify, or terminate client care B) To develop a prioritized list of client-centered problems C) To develop an individualized plan of client care D) To determine the client's health status
B) To develop a prioritized list of client-centered problems Diagnosing as part of the nursing process is meant to establish priorities of current and possible health problems of the client. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Outcome identification and planning specify the nursing diagnosis to the client's strengths, thereby individualizing the plan of care. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care.
The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using: A) acute observation ability. B) intuitive problem identification. C) illogical thinking. D) an assumption to guide practice.
B) intuitive problem identification. Experienced nurses are able to make clinical decisions based on intuition, or an "inner prompting or hunch" that can lead to early and life-saving interventions. Intuitive problem solving is based on a background of experience, knowledge, and skill. Acute observation ability is using skills to determine the extent of the issue using observation. Logical fallacies (illogical thinking) are used to describe faults in logic that result in false conclusions. Assumption a thing that is accepted as true or as certain to happen, without proof.
A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is newly diagnosed, the nurse included in the plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in the client? The client will: A) log all meals in a diary for the next 6 weeks. B) maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). C) maintain a normal HgbA1C. D) not exhibit signs and symptoms of hypoglycemia/hyperglycemia.
B) maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). Outcomes can be short- or long-term, and short-term outcomes should describe a single, observable, and measurable behavior. Maintaining a blood sugar between 70 and 110 mg/dL (3.89 and 6.11 mmol/L) is short-term and is a single, observable, measurable outcome. Logging meals for 6 weeks and maintaining a normal HgbA1C are more long-term goals. Not exhibiting signs and symptoms of hypoglycemia/hyperglycemia is not as measurable/observable as monitoring the blood sugar.
Which statements are true about the implementation phase of the nursing process? Select all that apply. A) All interventions carried out during this phase must be accompanied by a physician's order. B) Care provided during implementation should be documented in the client's chart. C) Implementation is only carried out by nursing professionals. D) Implementation is the process of carrying out the plan of care. E) This phase promotes wellness and restores health.
C) Care provided during implementation should be documented in the client's chart. D) Implementation is the process of carrying out the plan of care. E) This phase promotes wellness and restores health. The implementation phase is the phase of the nursing process in which the plan of care is carried out. It is designed to promote wellness and restore health to clients through interventions that are collaborative and nursing driven. Not all interventions included in this phase have to be accompanied by a physician's order. Interventions are collaborative in that more than nursing professionals are involved in restoring health to the client.
A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply. A) Heart failure B) Pneunomia C) Impaired mobility D) Imbalanced nutrition E) Ineffective coping
C) Impaired mobility D) Imbalanced nutrition E) Ineffective coping The North American Nursing Diagnosis Association (NANDA)-International defines nursing diagnosis as "a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes." A medical diagnosis describes a disease, whereas a nursing diagnosis describes an individual, family, or group response to an actual or potential health problem. A nursing diagnosis provides the basis for selection of nursing interventions to achieve positive client outcomes.
The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next? A) Develop an additional nursing diagnosis to meet the client's health needs. B) Change the nursing diagnosis because the client's problem was falsely identified. C) Modify the plan of care and interventions to meet the client's needs. D) Reassess the client for more symptoms of deficient fluid volume.
C) Modify the plan of care and interventions to meet the client's needs. The nurse should review the plan of care and its implementation periodically and, as needed based on evaluation, modify them to meet the client's needs. Because this client continues to exhibit symptoms identified by the nursing diagnosis, the implementation should be modified to better meet the client's needs and outcomes. Because the original nursing diagnosis appears to be accurate, there is no indication that it falsely identifies the client's problem or that another one is needed. There is no need to reassess the client for more symptoms of deficient fluid volume because it is evident that the client has this problem.
Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: A) applies intuition and routine care for clients. B) employs communication to meet the client's needs. C) uses critical thinking to direct care for the individual client. D)uses scientific problem solving to meet client problems.
C) uses critical thinking to direct care for the individual client. The nursing process requires blended skills and critical thinking. Critical thinkers think systematically about the nursing process and apply it for the individual client. Communication is important but not sufficient to meet client needs, and scientific problem solving is used in the laboratory setting, not nursing.
A nurse is working with a group of staff members to address the needs of a client as they develop the client's interdisciplinary plan of care. Which question if asked by the nurse addresses the standard of breadth when judging the group's thinking? A) "Could you elaborate on that point a bit more?" B) "How could we find out whether that is true?" C) "Could you be more specific in your observations?" D) "Is there another way to look at this situation?"
D) "Is there another way to look at this situation?" Breadth is demonstrated by asking whether there is another way to look at this situation. This question attempts to address other issues that may or may not be impacting the situation. Asking to elaborate demonstrates clarity; asking to find out if the issue is true reflects accuracy. The question about being more specific addresses precision.
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? A) Check the client's skin turgor. B) Formulate a plan of care based on risk for dehydration. C) Administer an additional liter of intravenous fluids. D) Determine whether the prescribed treatment was effective.
D) Determine whether the prescribed treatment was effective. The sequence of the nursing process is assessment, diagnosis, planning, implementation, and evaluation. Checking skin turgor is an assessment. Formulating a care plan is part of planning. Administration of additional fluid occurs during implementation. The nurse evaluates whether the intervention was effective, as demonstrated by a rise in blood pressure and a decline in pulse rate.
Which is the most appropriate example of the assessment phase of the nursing process? A) Documenting the administration of a medication provided for pain B) Evaluating the temperature of a client given medication for a fever C) Including a nursing diagnosis of Acute Pain in the client's plan of care D) Palpating a mass in the right lower quadrant of the abdomen
D) Palpating a mass in the right lower quadrant of the abdomen Palpation of a mass in the abdominal cavity is an example of assessment in the nursing process through collecting data that determine the need for nursing care. Documentation of medication administration is an intervention. Evaluating the temperature of a client given medication for a fever is a better example of evaluation through assessment. Including a nursing diagnosis in the plan of care is part of determining actual and potential health problems.
A nurse has developed a plan of care for an adult client. What nursing function is important when using nursing diagnoses to guide the care of this client? A) Add a new nursing diagnosis in the nurse's own words to individualize the plan of care. B) Keep resolved nursing diagnoses as part of the plan of care in case the related problems return. C) Do not allow the client to review the client's own nursing diagnoses. D) Prioritize the nursing diagnoses.
D) Prioritize the nursing diagnosis After performing a nursing assessment, data should be analyzed and compiled into actual and potential health problems and documented as nursing diagnoses. It is the nurse's responsibility to prioritize the nursing diagnoses, thereby prioritizing the care of the client. Resolved nursing diagnoses should be deleted from the plan of care as soon as they are resolved and replaced with new ones when appropriate. Nursing diagnoses should be written in a nonjudgmental way and in legally advisable terms, not in the nurse's own words. The plan of care is individualized for each client, and therefore the client should be aware of what is included.
The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next? A) Cover the infant. B) Ask the parent whether the child has been exposed to cold temperatures. C) Assess the skin for signs of cyanosis. D) Recheck the temperature, paying close attention to technique.
D) Recheck the temperature, paying close attention to technique. Tympanic membrane thermometers are noninvasive and fast to use, but studies show discrepancies between their readings and those of oral thermometers, resulting in both false-positive and false-negative readings. The nurse can minimize these discrepancies by using the same ear and device for measurement each time and by using proper technique. The other actions listed would be appropriate for the nurse to take after rechecking the infant's temperature and confirming that it actually is lower than normal.
In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged? A) Recalling a sequence of events B) Identifying a positive situation C) Thinking about relationships involved D) Reevaluating experience in light of ideas
D) Reevaluating experience in light of ideas Reflection at the higher level includes reevaluating experience in the light of ideas, behavior, feelings, and values. Reflection at the basic level includes recalling the sequence of events, identifying a positive situation, and thinking about relationships involved.
The plan of care for a client with diabetes mellitus includes daily assessment of lab values. When assessed, these lab values are outside of the recommended range. The nurse collaborates with the health care provider and the client to change medications included in the plan of care. What characteristic of the nursing process does this illustrate? A) Dynamic B) Interpersonal C) Outcome oriented D) Systematic
D) Systematic This is an example of how the nursing process is systematic. Each part of the nursing process depends on a sequence of activities; each step depends on the one that precedes it and influences the outcome. In this example, the nurse requires assessment of the client's lab values to determine a weakness in the plan of care that must be addressed through collaboration with the client and the health care provider. This will help determine a new plan of action or outcome so that interventions can be implemented and reevaluated. This scenario does not demonstrate that nursing process is dynamic because illustrates the expected progression of activities within the nursing process, from the development and implementation of the plan of care to the evaluation and subsequent necessary modifications to the plan of care. It does not particularly demonstrate the use of interpersonal skills by the nurse. The outcome-oriented nature of the nursing process is more evident in the planning phase than in the evaluation phase.
The nurse is caring for a pediatric client with respiratory distress. Upon assessment the client has increased respirations and work of breathing (WOB). Breath sounds are adventitious and the client has thick yellow/green drainage coming from the nose. Based on these findings, the nurse determines that this client has an ineffective airway clearance related to copious amounts of thick secretions and proceeds to perform nasopharyngeal suctioning to relieve some of the secretions. If the nurse were documenting the evaluation of this intervention, what would be documented? A) Increased respirations, increased WOB, adventitious breath sounds, thick nasal secretions B) Ineffective airway clearance related to copious amounts of thick secretions C) Nasopharyngeal suctioning D) The amount and type of drainage suctioned from the nares, and the client's response
D) The amount and type of drainage suctioned from the nares, and the client's response The evaluation phase is the phase of the nursing process in which the client's response to the plan of care is analyzed and decisions are made to continue, revise, or terminate the plan of care. The amount and type of drainage and the client's response to the nasopharyngeal suctioning is the evaluation and should be documented. The client's symptoms are documented as part of the assessment. Ineffective airway clearance is documented as the nursing diagnosis. Nasopharyngeal suctioning is documented as the intervention.
How can the nurse obtain a more complete database for a newly admitted client? A) Clustering of data B) Analysis of lab values C) Review of the chart D) Comprehensive client assessment
D) comprehensive client assessment By having a more complete database from several sources, including the client, the nurse can arrive at a more accurate conclusion. The nurse can obtain data from secondary sources, such as family members, significant others, other health care professionals, health records, and literature review. Clustering of data, analysis of laboratory values, and review of the chart are all done after gathering data through assessment to develop nursing diagnoses; they would not help the nurse gather more data on the client.
