CH 13 Blended Competencies, Clinical Reasoning and Processes of Person-Centered Care
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?
Planning; implementing
Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?
Reflection
Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:
uses critical thinking to direct care for the individual client.
A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask?
"What happened?"
The nurse is caring for an underweight female client diagnosed with a new food allergy to wheat, rye, and oats and with the nurse identifies the nursing concern of altered nutrition that is less the required. What is the most appropriate intervention for this client?
Administer a high-calorie diet, excluding wheat, rye, and oats.
Which behaviors are characteristic of a nurse who is a critical thinker? Select all that apply.
Alert to context so that the need for modification can be identified and changes to the plan of care can be made Responsible and accountable for own actions
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?
Analyze the data and create an individualized nursing concern for care planning.
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 next nursing action?
Assess the client's back visually.
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?
Assessment
Which activity is the clearest example of the evaluation step in the nursing process?
Checking the client's blood pressure 30 minutes after administering captopril
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?
Clarity
A nurse has identified a nursing concern of altered nutrition based on the client's continued weight loss despite adequate intake. During the implementation phase of the nursing process, which activity(ies) is appropriate for the nurse to perform in care of this client? Select all that apply.
Contact a dietitian to perform a calorie count. Ask the family to bring in a home-cooked meal. Administer 100 ml of nutritional supplement as prescribed at bedtime.
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?
Determine whether the prescribed treatment was effective
The nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying?
Developing accountability
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?
Document this assessment based on the client's behaviors.
Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing?
Evidence-based practice
Which is a characteristic of person-centered care?
It is a framework for providing care.
A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?
Nursing process
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?
Experiental
The nurse has entered the room of a newly admitted client who immediately reports feeling short of breath. After identifying this as the client's problem, the nurse uses the process of scientific problem solving. Place the steps in the order the nurse would follow.
Identify the data Collect assessment data Formulate a hypothesis Make a plan for action Evaluate
Which statement best conveys the role of intuition in nurses' problem solving?
Intuition can be a clinically useful adjunct to logical problem solving.
A nurse who is not familiar with using automated intravenous (IV) pumps is moving to a unit that uses them frequently. The nurse is anxious about using the device. What is the most appropriate way for the nurse to lessen this anxiety?
Practice using the device under the supervision of a more experienced nurse before using it with a client.
A nurse has developed a plan of care for an adult client. What nursing function is important when using the identified nursing concerns to guide the care of this client?
Prioritize the nursing concerns.
What is the most beneficial use of the nursing process in addressing the needs of the client?
Provides a universally applicable framework for nursing activities
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?
Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.
The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?
Repositioning the client
Which statement is true of the nursing process?
Scientific problem solving can occur within the nursing process.
Which outcome is most appropriate for the nurse to include in the care plan for a client with the identified nursing concern of infection risk?
The client has a normal temperature and no signs or symptoms of infection.
What is the purpose of the diagnosis phase of the nursing process?
To develop a prioritized list of client-centered problems
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?
Trial-and-error problem solving
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?
activity and rest
A nurse has completed a client assessment and is preparing to identify appropriate nursing concerns. Which area(s) will the nurse likely address in the nursing concern? Select all that apply.
altered mobility altered nutrition ineffective coping
Put the phases of the nursing process in the correct order. Use all options.
assessment diagnosis planning implementation evaluation
A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:
complete the postoperative assessment.
A client's body mass index (BMI) categorizes the client as obese. The client comes to the clinic to start on a weight loss plan. The client loves to eat, does not like to exercise, and their favorite food is hamburgers. The nurse creates a care plan focused on the nursing concern altered health maintenance. What is the most appropriate outcome for this concern? The client will:
create an exercise plan that is realistic and valued.
The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?
involving the client with all the steps of the process in care development
A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified:
outcome.
Which is the most appropriate example of the assessment phase of the nursing process?
palpating a mass in the right lower quadrant of the abdomen
Self-evaluation is a method that nurses use to promote their own development and to grow in confidence in their nursing roles. This process is referred to as:
reflective practice.
What type of intervention is the nurse performing when the nurse observes the spouse of a postoperative client performing the client's dressing change?
supervisory
