Assessment ch. 5:Thinking Critically to Analyze Data and Make Informed Nursing Judgments

A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The student needs further explanation when making which statement?

"All patients have the same defining characteristics." The nurse should not overlook the patient's culture when analyzing data collected. Patients from different cultures may be misdiagnosed because the defining characteristics and labels for specific diagnoses do not always accurately describe the human responses in their culture. Therefore, it is essential to closely look at cultural norms and responses for various diverse patients.

A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?

"Can you tell me about your sleep problem from when it started until now?" In order to open the interview, the nurse should start with an open-ended question and then use the OLD CART mnemonic to identify missing data. Asking when the sleep problem began is assessing for onset of the problem. Asking the client to rate the sleep problem from 1 to 10 is part of assessing characteristic symptoms. Asking the client what has been tried to help with the sleep is assessing for treatments.

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?

"It was done to validate the reading."

Risk diagnosis

- A risk nursing diagnosis describes a situation in which an actual diagnosis will most likely occur if the nurse does not intervene

A community health nurse provides information to a patient with newly diagnosed multiple sclerosis for a support group at the local hospital for patients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following?

A referral Referring is the process of sending or guiding the patient to another source for assistance. Consultation is the process of inviting another professional to evaluate the patient and make recommendations to you about his or her treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of patient data to others.

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a patient who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered?

Actual Nursing Diagnosis This patient is having an actual problem--pain--which therefore would be classified as an actual nursing diagnosis and provides a description of the problem that the patient is currently having.

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.)

Be nonjudgmental and keep an open mind. Acquire an adequate knowledge base that continues to build. Use rationale to support opinions or decisions. The essential elements of critical thinking are: Keep an open mind, use rationale to support opinions or decisions, reflect on thoughts before reaching a conclusion, use past clinical experiences to build knowledge, acquire an adequate knowledge base that continues to build, be aware of the interactions of others, and be aware of the environment.

What can the nurse use to learn new information and add to their knowledge base?

Clinical experience. The critical thinker uses each clinical experience to learn new information and to add to the knowledge base. Another important aspect of critical thinking involves awareness of human interactions and the environment, which provides cues and directly influence decisions and judgments.

What is pivotal to determining how to move from each client problem to its goals?

Clinical reasoning process Clinical reasoning process is pivotal to determining how the nurse interprets the client's history and physical examination, single out the problems listed in assessment, and move from each problem to its goals and then the implementation with specific nursing interventions.

A client admitted to a health care facility for injuries received in a motor vehicle accident is given the nursing diagnosis of Impaired Nutrition: Less than Body Requirements. What change in the client's dietary requirements should the nurse anticipate?

Encourage intake of high density foods several times a day Based on the nursing diagnosis of the client that is Impaired Nutrition: Less than Body Requirements, the client would be required to increase food intake to promote healing. The best way for the nurse to assist the client is to offer high density foods several times a day to increase the total number of calories consumed while still maintaining adequate nutrition.

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse?

Make a referral to the dietician. Referring can be defined as connecting clients with other professionals and resources. This client would receive the greatest benefit from the professional that is able to give them the education required to manage their disease process.

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission?

Medication reconciliation Medication reconciliation is a preventive measure to ensure the continuity of care for a client and the continuation of medications taken at home that are necessary for the client's well being. SBAR is a communication tool to ensure appropriate information is given to the healthcare provider to care for the client. High-alert labeling is utilized to identify many sound alike medications. The teaching of side effects is crucial to informed care, yet is not the most likely cause of omission of medication from home.

A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case?

Overlooking consideration of the clients cultural background The nurse erred in this case by interpreting the lack of eye contact on the part of the client as an unwillingness to listen to recommendations. In some cultures, including Japanese, eye contact is not considered appropriate in certain social situations. The other errors listed do not apply in this case, as the nurse did not cluster together unrelated cues, diagnose the client without hypothesizing several diagnoses, or incorrectly word a diagnostic statement.

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse?

Reassess blood pressure The nurse can delegate the monitoring and documenting of specific assessments to UAPs; but the nurse always retain the responsibility to interpret delegated assessment data to evaluate the patient's condition. The nurse should retake the blood pressure immediately as it is abnormally low for this patient. Having the UAP retake the blood pressure does not allow the nurse to evaluate the client or assess the accuracy of the UAP's ability to take a blood pressure. The physician should not be notified until the blood presser has been reassessed.

The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action?

Review the client's prescribed medication orders. The nurse should review the client's current orders to confirm which IV solution should be infused. Hanging the IV bag that was left on the pole is assuming that the assigned nurse hung the correct IV solution. Nurses should always verify orders themselves. Obtaining a bag of the current IV solution to hang is assuming, rather than verifying, as well. Discontinuing the solution is not necessary while verifying the orders.

Select the following nursing diagnosis that is correctly stated.

Risk for Impaired Skin Integrity related to immobility secondary to right-sided paralysis, dehydration, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin. A risk diagnosis describes a situation in which an actual diagnosis will most likely occur if the nurse does not intervene. In this case, the client does not have any symptoms or defining characteristics that are manifested, thus a shorter statement is sufficient: Risk for + diagnostic label + r/t + etiology.

When teaching the students about becoming effective diagnosticians, the nursing instructor includes the following common errors made by novice nurses. (Select all the apply.)

See things as either right or wrong. Focus only on the details.

A nurse assesses an older adult client with confusion. When collecting clinical information from the client, which factor is the most important for the nurse to consider?

The quality of the data may be low. Due to client confusion, the quality of the data obtained directly from the client will likely be low. In order to ensure the quality of the client data, the nurse will need to confer with colleagues and client family members. In addition, the nurse should review the client history and pertinent literature to clarify uncertainties. The incorrect options may be likely; however, they are not possible if the nurse is unable to obtain reliable assessment data.

A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client?

Unable to feel his leg Based on the conditions in which the client has been brought to the health care facility, the client's inability to feel his legs can be noted as a subjective abnormal finding. Data such as the client is bleeding profusely from the wound and the presence of lethargy and confusion should be noted as objective abnormal findings.

What should the nurse do prior to analyzing data collected on a patient with Addison's disease? (Select all that apply)

Validate data. Document data. Collect and organize assessment data.

Conferring

is to consult with someone to exchange ideas or seek information, advice, or instructions.

Collaborative problems and referrals

ould be documented as risk for complications (RC: ____ (what the problem is). - Nursing goals for the collaborative problem also should be documented as which parameters the nurse must monitor and how often they should be monitored - The nurse needs to indicate when the physician or NP should be notified; identify interventions to prevent complications, and when referrals are ne

Critical thinking is the way the nurse processes?

the information (using knowledge, past experiences, intuition, and cognitive abilities) to formulate nursing diagnoses

Data analysis is what phase in the nursing process ?

the second * referred to as diagnostic phase or clinical reasoning phase The end result or purpose is identification of a nursing diagnosis

A nurse understands that the identified strengths found during the assessment of a patient are used for which of the following nursing diagnoses?

wellness diagnosis The nurse formulates a wellness diagnosis using identified strengths. Identified potential weaknesses help in formulating risk diagnoses. Abnormal findings are used to formulate actual nursing diagnoses. No potential strengths diagnoses have been identified.

A nursing student is explaining to a roommate the relationship between diagnostic reasoning and critical thinking. Which of the following is the correct statement for the nursing student to make?

"Diagnostic reasoning is a form of critical thinking used to interpret data correctly." As the second step or phase of the nursing process, data analysis is a very difficult step because the nurse is required to use diagnostic reasoning skills to interpret data accurately. Diagnostic reasoning is a form of critical thinking.

A patient has 3+ pitting edema, crackles in lungs, and dyspnea. The nurse is monitoring the patient's vital signs and O2 saturations, and the physician has prescribed 40 mg of intravenous Furosemide (Lasix). What type of problem is this considered?

Collaborative problem Collaborative problems are defined as "certain physiological complications that nurses monitor to detect their onset or changes in status; nurse manage collaborative problems using physician-prescribed and nursing-prescribed interventions to minimize the complication of events.

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?

Diagnostic reasoning skills are required to interpret data accurately.

You are the office nurse admitting a new patient to the clinic. You have gained your patient's trust, gathered a detailed history, and finished your portion of the physical examination. What is your next step in caring for this patient?

Identify the patient's problems During the time spent with your patient, you have gained your patient's trust, gathered a detailed history, and completed the requisite portions of the physical examination. You have reached the critical step of formulating your Assessment, Nursing Diagnosis, and Plan. You must now analyze your findings and identify the patient's problems, then share your impressions with the patient, eliciting any concerns and making sure that he or she understands and agrees to the steps ahead. Finally, you must document your findings in the patient's record in a succinct and legible format that communicates the patient's story and your clinical reasoning and plan to other members of the health care team.

The nurse is completing an assessment of a patient who reports two episodes of fainting in the late afternoon. Which data would the nurse categorize as subjective?

Increase in psycho-social stress Subjective data is that which the patient says is occurring. The patient would describe the experience of increased psycho-social stress and the nature of the stress in relation to her own perception of it. The nurse would not be able to observe a patient's stress. Objective information is that which is observed during an assessment. Blood pressure, respiratory rate, and heart rate/rhythm are all objective data.

A male client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse?

Place on cardiac monitor. The nurse should prioritize care and address physiological, urgent needs first. The client should be placed on the cardiac monitor. The health history and medication use data can be collected while the client is being monitored. The nurse should ask the client about any allergies first as the client may be allergic to certain stickers used for cardiac monitoring. However, any allergies can be recorded after place on continous monitoring.

Reporting

is the oral, written, or computer-based communication of patient data to others.

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the patient has the opportunity for an enhanced health state:

wellness diagnosis A wellness diagnosis indicates that the patient has the opportunity for enhancement of a health state. A risk diagnosis indicates that the patient does not currently have the problem, but is at high risk for developing it. An actual diagnosis indicates that the patient is currently experiencing the stated problem or has a dysfunctional pattern. A medical diagnosis is treated by the physician and is usually stated as a disease process.

One characteristic of a nurse who is a critical thinker is the ability to

validate information and judgments. One characteristic of a critical thinker is the ability to validate information and judgments with experts in the field.

The nurse has learned that after completing the assesment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do?

Analyze the data The second phase of the nursing process is the diagnostic phase, in which the nurse analyzes the data collected. Organizing, validating, and collecting data all occur during the first phase, which is step one or assessment.

The RN may delegate which care component to a nursing assistant?

Ambulation assistance The RN may delegate individual components of care but does not delegate the nursing process itself. The main functions of assessment, planning, evaluation, and nursing judgment cannot be delegated. For example, if the nurse delegates taking vital signs to a nursing assistant, he or she is responsible for making sure that the data is accurately collected and for following up if findings are abnormal. The nursing assistant may collect vital signs, but the RN is responsible for evalutation. Assessment is always the RN's responsibility, which includes wound assessment and assessing pain level.

A nurse interacts with four different clients one afternoon at the health clinic. The nurse is able to directly assist three of them and makes a referral for the fourth. Which of the following patients should the nurse refer to another professional?

An elderly woman who needs daily therapy sessions to help her walk again after a hip fracture Referral is used for identified problems for which the nurse cannot prescribe definitive treatment. Referring can be defined as connecting clients with other professionals and resources. Teaching a client how to self-inject insulin, counseling a pregnant woman on prenatal vitamins, and administering a flu vaccine are all interventions that a nurse can easily accomplish. Providing daily therapy sessions to help an elderly woman walk again after a hip fracture, however, would be beyond the scope of practice of the nurse and should be referred to a physical therapist.

A patient comes to the clinic for a yearly physical examination. The assessment reveals multiple lesions on the face, neck, arms, and legs. The patient appears upset, starts to cry when questioned about the skin abnormalities, and asks the nurse if the problem is skin cancer. What would be the best nursing diagnosis for this patient?

Anxiety related to lesions on body A wellness diagnosis indicates that the patient has the opportunity for enhancement of a health state. A risk diagnosis indicates the patient does not have the problem but is at high risk for developing it. An actual diagnosis indicates that the patient is currently experiencing the stated problem. In this case, the patient is definitely experiencing anxiety over skin lesions being cancer.

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data?

Anxious appearance Based on the data gathered from the client, the nurse can classify the anxious appearance of the client as an objective abnormal finding. Complaints of hair loss and having an itching sensation are information provided by the client, and worrying about her appearance is an inference the nurse is making; all of these are subjective abnormal findings.

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan?

Ask the client for opinions and willingness to proceed with the interventions The plan of care should be agreeable to the patient. Before finalizing the plan, it is important for the nurse to share the information with the patient and seek out opinions and willingness to proceed with the interventions. Although discussing the plan of care with the all health care providers involved, involving the client in the process is the only way to know if the goals are realistic for his unique needs. Sharing the assessment and plan of care with the client's primary health care provider will only be necessary once the client has voiced his opinion and willingness to proceed with the interventions. The client's family should be involved in the plan of care and likely serve to make it more effective. The client must agree first and demonstrate willingness prior to discussing it with the family.

The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to

discuss the plan with the patient Sharing the assessment and plan with the patient will allow the patient to offer his or her opinion, concerns, and willingness to proceed with the interventions. This makes the patient an active participant in his or her plan of care.

A hospitalized client is prescribed a short course of corticosteroids. The client is placed on sliding scale regular insulin. The nurse should routinely assess which laboratory value while the client is hospitalized?

Capillary blood glucose The client has been placed on short term steroids which can lead to elevated glucose levels. Therefore, the glucose level should be monitored. The hemoglobin A1C level is monitored for long term diabetic control. Hematocrit levels and sodium electrolytes are not affected as readily as glucose levels.

Setting Priorities as Part of Critical Thinking

Learn to prioritize problems • 1st level problems (emergent, life threatening) - ABCs (airway, breathing, cardiac/circulation problems, Vital Signs concerns) • 2nd level (require prompt intervention) - MUAAAR: Mental status change, Untreated medical problems requiring immediate attention; Acute pain, Acute urinary elimination problems, Abnormal labs, Risks—safety, infection or security

A nurse is writing down hunches about certain cue clusters related to a client. Which of the following hunches would seem to indicate the need to generate a collaborative problem as opposed to a nursing diagnosis?

Inflamed appendix is causing severe abdominal pain. If the inference you draw from a cue cluster suggests the need for both medical and nursing interventions to resolve the problem, you would attempt to generate collaborative problems. An inflamed appendix, or appendicitis, typically requires a medical (surgical) intervention and thus would be a collaborative problem. The other problems listed (poorly managed stress, lack of knowledge about vaccinations, and lack of exercise) are ones that nurses can typically address on their own.

The new graduate nurse feels overwhelmed with the volume of data collected on a client with multiple health problems. How should the nurse prepare to critically analyze this data?

Keep an open mind The nurse must develop personal characteristics to think critically. An open mind is essential when making judgments and plans. Asking for help does not support the new nurse's problem-solving and analyzing skills. Asking a seasoned nurse to look over the outcome of the analysis would be more appropriate. Reviewing disease processes in a textbook would not necessarily help the nurse critically analyze the data. Talking over priorities with the charge nurse would not necessarily help the nurse critically analyze the data.

Seven Essential Critical Thinking Characteristics (

Keep an open mind. • Use rationale to support opinions or decisions. • Reflect on thoughts before reaching a conclusion. • Use past clinical experiences to build knowledge. • Acquire an adequate knowledge base that continues to build. • Be aware of the interactions of others. • Be aware of the environment.

The Diagnostic Reasoning Process

Step one ‐ Identify abnormal data and strengths - Subjective data - Objective data Step two ‐ Cluster data - Identify abnormal findings and strengths that are related. - Consider, again, if additional data are needed Step three ‐ Draw inferences - Write down "hunches." - Consider nursing diagnosis, collaborative problem and referral • May need referral (notification) to other to other discipline • Nurse may need to collaborate with physician, physical therapy to best meet patient needs Step four: Propose possible nursing diagnoses - Actual diagnosis - a problem the client is currently experiencing or had a dysfunctional pattern - Risk diagnosis - client does not have but has potential to develop - Health promotion diagnosis ‐ opportunity for enhancement of health state Step five - Check for defining characteristics - Use reference text such as NANDA Nursing Diagnoses: Definitions and Classifications 2007 - 2008. - Defining characteristics list criteria to meet a certain diagnosis • For example, in order to use the nursing diagnosis "Impaired Gas Exchange", one criteria may be to have a low oxygen saturation documented. - Compare your findings to NANDA Step six ‐ Confirm or rule out diagnosis - Validate diagnosis with client and other health care providers who are caring for the client. - Validation is also important if client has collaborative problem or requires a referral Step seven ‐ Document conclusions - Actual nursing diagnoses - Risk diagnosis • In 3320 we will focus on Actual and Risk Diagnoses

The nurse observes no urine output in a client's indwelling urinary catheter drainage bag. What is the nurse's first action?

Verify positioning of the catheter. The nurse should follow the nursing process and complete the assessment of the catheter first, which includes checking position of the catheter. Applying suprapubic pressure, performing a bladder scan, and collecting a urine specimen are not the first actions before a complete assessment.

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client?

Weight gain of 3 pounds (1.5 kilograms) over 1-2 days Nursing diagnoses are based on alterations in body system processes, lifestyle, personal issues, and specific causes. For the client with heart failure, the problem that would have the highest priority would be the weight gain of 3 pounds (1.5 kilograms) over 1-2 days. This change can related to a decline in cardiac functioning and needs to be addressed first. Once this priority problem has been investigated, other problems can be addressed. Ineffective health maintenance can be addressed last. Knowledge deficit related to lack of information regarding low-sodium diet would be the next in priority after activity intolerance because learning how to reduce sodium could help control the heart failure. Anxiety about hospitalization and inability to attend to home and work needs would be addressed after the knowledge deficit.

The nurse is working with a 14-year-old girl who has told the nurse that she would like to try getting to bed a little sooner to get a full night's sleep and have more energy at school. The nurse diagnoses her with the following: Readiness for enhanced sleep related to client's expressed desire to go to bed earlier. Which type of nursing diagnosis is this?

Wellness Health promotion diagnoses represent those situations in which the client does not have a problem but is at a point at which a higher level of health can be attained. In other words, this client has the desire to increase her well-being and actualize her human potential. This type of diagnosis is often worded readiness for enhanced. It indicates an opportunity to make greater, to increase quality of, or to attain the most desired level of function in the area of the diagnostic category. The other answers clearly do not describe this diagnosis.

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information?

Wellness diagnosis A wellness diagnosis indicates that the client is ready to make changes to enhance his healthy state. The client states that he wants to lose weight and increase his exercise routine. A collaborative problem is one that suggests the need for both medical and nursing interventions to resolve the problem. A risk diagnosis indicates that the client does not currently have the problem but is at high risk for developing it. A referral, in which the nurse connects the client with other professionals and resources, is not necessary unless the nurse cannot assist the client with his needs.

The nurse understands that, after clustering data and drawing inferences, if the problem is something a nurse could manage independently the next step would be which of the following

analyzing the data After clustering data, the nurse writes down hunches and determines whether it is something that the nurse can treat independently. If so the nurse can intervene and then move to the next step, which is analysis of data to formulate a nursing diagnosis. Identifying abnormal data is step one, confirming the diagnosis is step six, and documenting conclusions is the last step.

When the nurse knows after drawing an inference that there is a need for both medical and nursing interventions, the patient's problem is which type?

collaborative problem If the inference the nurse draws after clustering cues suggests the need for both medical and nursing interventions to resolve the problem, you would attempt to generate collaborative problems. Dependent problems require physician input; independent problems can be resolved solely by the nurse. Personal problems are not characterized individually as a separate type of patient problem.

A patient who is 2 days postoperative reports pain and requests pain medication. After assessing the patient's pain level, the nurse decides to give the patient oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?

implementation This step is implementation, because the nurse is taking appropriate action by giving oral medication. Assessment is the first step of the nursing process when the nurse collects data. Diagnosis is determining the problem. Evaluation is the final step to see if patient has achieved established goals.

A nurse is working with a patient who has a history of chronic obstructive pulmonary disease (COPD). While bathing the patient, the nurse senses that something is not quite right and takes the patient's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following?

intuition The nurse is acting on intuition, in this case, the feeling that something is not quite right. Scientific rationale is an explanation based on science. Knowledge is based on science and theories that the nurse learned in school. Prior history of the patient is not what the nurse is acting upon in this case.

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?

nursing diagnosis Data analysis is referred to as the diagnostic phase of the nursing process because the end result is the identification of a nursing diagnosis. A nursing intervention is done during the implementation phase, nursing rationale is identified when choosing the interventions, and data organization must be done during the collection of the data while still in the assessment phase.

Consultation

process of inviting another professional to evaluate the patient and make recommendations to you about his or her treatment.

A nurse is aware that when identifying abnormal data and strengths of the patient to make a diagnosis, it is mandatory that the nurse considers which of the following?

risk factors Identifying abnormal findings and patient strengths requires the nurse to have and use a knowledge base of anatomy and physiology, psychology, and sociology. Also the nurse should have a basic knowledge of risk factors for the patient. Risk factors are based on patient data such as gender, age, ethnic background, and occupation. Money, type of insurance, and food preferences are not identifiable risk factors.

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning

seeing things as only right or wrong Developing expertise with making professional judgments comes with accumulation of both knowledge and experience. It is a process that develops over time and with practice. Seeing things as only right or wrong does not allow for seeing things as gray and may make you miss the bigger picture.

The nurse is required to use diagnostic reasoning skills to?

to interpret data accurately