Chapter 5: Analyze Data to Make Informed Clinical Judgments

The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good critical thinking skills, but don't really understand what that is?" What is the best response by the preceptor? -"Being open-minded in order to provide professional nursing care." -"A way of processing information using to formulate conclusions or diagnoses." -"A way of problem solving so that you can transform from a novice to expert nurse." -"A way to think so that you can solve problems."

"A way of processing information using to formulate conclusions or diagnoses."

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? -"Critical thinking and diagnostic reasoning are not related." -"Critical thinking is a form of diagnostic reasoning used to interpret data correctly." -"Diagnostic reasoning is used in assessment, whereas critical thinking is used in analysis." -"Diagnostic reasoning is a form of critical thinking used to interpret data correctly."

"Diagnostic reasoning is a form of critical thinking used to interpret data correctly."

The nurse receives a report on a group of clients. What client statement requires further clarification to ensure client safety? Select all that apply. -"I fell at home last month." -"My daughter will be visiting today." -"I do not usually take insulin." -"I feel much better today." -"This looks like a new pill."

"I do not usually take insulin." "This looks like a new pill." "I fell at home last month."

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? -"The nursing assistant had difficulty with the reading." -"The first reading was measured too early." -"The second reading was used as a guide for providing a medication." -"It was done to validate the reading."

"It was done to validate the reading."

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.) -Only validate data that you see, not what the client tells you. -Use rationale to support opinions or decisions. -Do not reflect on your thoughts, just make a decision. -Acquire an adequate knowledge base that continues to build. -Be nonjudgmental and keep an open mind.

-Acquire an adequate knowledge base that continues to build. -Be nonjudgmental and keep an open mind. -Use rationale to support opinions or decisions.

The nurse reviews data collected during an assessment. Which data should the nurse validate? Select all that apply. -Data that is inconsistent with another finding -Evening temperature higher than morning temperature -Respiratory rate slower during sleep than while awake -Subjective and objective data are inconsistent -Gap between what the client said and what is in the medical record

-Subjective and objective data are inconsistent -Gap between what the client said and what is in the medical record -Data that is inconsistent with another finding

The nurse educator is teaching nursing students about critical thinking to ensure appropriate clinical judgments. Which of the following should the nurse educator include in this teaching session? Select all that apply. -Base decisions solely on clinical and educational experiences. -Use rationale and research to support decisions. -Reflect on past experiences and thoughts before reaching a conclusion. -Acquire an adequate knowledge base from ongoing education and professional journals. -Keep an open mind and listen to what others have to say before making a decision.

-Use rationale and research to support decisions. -Reflect on past experiences and thoughts before reaching a conclusion. -Acquire an adequate knowledge base from ongoing education and professional journals. -Keep an open mind and listen to what others have to say before making a decision.

Which of the following sequences describes the correct order of steps the nurse should take when analyzing data? -Cluster data and draw inferences -Propose possible nursing diagnoses -Identify abnormal data and strengths -Document conclusions -Check for the presence of defining characteristics -Confirm or rule out nursing diagnoses

1.Identify abnormal data and strengths 2.Cluster data and draw inferences 3.Propose possible nursing diagnoses 4.Check for the presence of defining characteristics 5.Confirm or rule out nursing diagnoses 6.Document conclusions

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a client who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered? -Wellness Nursing Diagnosis -Risk Nursing Diagnosis -Rule Out Nursing Diagnosis -Actual Nursing Diagnosis

Actual Nursing Diagnosis

A nurse is preparing to document conclusions after analyzing data and includes information about related factors and manifestations. What is the nurse formulating? -Problem for referral -Actual nursing diagnosis -Collaborative problem -Risk nursing diagnosis

Actual nursing diagnosis

The nurse has learned that after completing the assessment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do? -Collect the data -Organize the data -Validate the data -Analyze the data

Analyze the data

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? -Identify the needs of the client's family in relation to the priority problem. -Ask the client for opinions and willingness to proceed with the interventions. -Discuss the plan of care with all of the health care providers involved. -Share the assessment and plan with the client's primary health care provider.

Ask the client for opinions and willingness to proceed with the interventions.

What can the nurse use to learn new information and add to their knowledge base? -Clinical experience. -Doing several written care plans -Past experience of other nurses. -Reading a medical-surgical textbook.

Clinical experience.

What is pivotal to determining how to move from each client problem to its goals? -Evaluation as an accurate historian of the client -Positive interpretation of the client's history -Process in collecting physical data -Clinical reasoning process

Clinical reasoning process

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

Collaborative problem

The nurse collected extensive data during a client assessment and is performing the first step in the process of data analysis. Successful completion of this step requires the nurse to do which of the following? -Differentiate between expected findings and abnormal findings. -Perform health promotion education. -Validate nursing diagnoses with the client and the client's family. -Integrate the client's medical diagnosis with nursing diagnoses.

Differentiate between expected findings and abnormal findings.

A nurse is performing a self-assessment of ability to think critically, making a list of characteristic behaviors. Which of the following behaviors would indicate critical thinking? -Biases typically affecting one's decisions -Exploring many alternatives before making a decision -A belief in one's infallibility -Facts and opinions are the same in one's mind

Exploring many alternatives before making a decision

During the assessment interview, the client made numerous statements that suggested his life generally exists in a state of harmony and balance. The nurse would document this as which type of nursing diagnosis? -Risk nursing diagnosis -Collaborative problem -Health promotion diagnosis -Actual nursing diagnosis

Health promotion diagnosis

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? -Lack of knowledge about the importance of vaccinations is increasing risks of illness. -Inflamed appendix is causing severe abdominal pain. -Poorly managed stress is causing diarrhea. -Lack of exercise is leading to obesity.

Inflamed appendix is causing severe abdominal pain.

A nursing instructor is describing why data analysis is considered a very difficult step in the nursing process. Which of the following would the instructor identify? -Conclusions must be documented. -Abnormal data must be identified. -It ends a decision about a nursing diagnosis. -It requires diagnostic reasoning skills.

It requires diagnostic reasoning skills.

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? -Call the physician and ask them to come and talk -with the client about their diet. -Give the client a printed diet. -Inform the client that they can look up a diabetic diet on the internet. -Make a referral to the dietician.

Make a referral to the dietician.

A nurse is providing care for a client who has chronic type 2 diabetes. In recent days, the client's blood glucose levels have been higher and more volatile than usual. After drawing this inference, the nurse should take what action? -Document the medical diagnosis of hyperglycemia -Assess the client more frequently -Beginning collecting subjective data -Make appropriate referrals

Make appropriate referrals

A nurse has completed data analysis. Which of the following would the nurse identify first as the result? -Outcome evaluation -Plan of care -Interventions -Nursing diagnosis

Nursing diagnosis

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 -Incorrectly wording a diagnostic statement -Clustering together unrelated cues -Diagnosing a client without hypothesizing several diagnoses

Overlooking consideration of the clients cultural background

An unlicensed assistive personnel (UAP) reports a low oxygen saturation level of 85% on a client. The nurse enters the room to find the client talking on the phone with a family member, laughing. What is the first action of the nurse? -Recheck the client's oxygen saturation. -Perform a focused respiratory assessment. -Return when the client is off the phone. -Apply oxygen via nasal cannula.

Recheck the client's oxygen saturation.

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? -Hang the IV solution the client's assigned nurse left on the pole. -Obtain an IV bag of the current solution and hang it. -Review the client's prescribed medication orders. -Discontinue the current solution and disconnect it from the client.

Review the client's prescribed medication orders.

A nurse's data analysis has led to the formulation of a risk nursing diagnosis. Which diagnosis demonstrates an accurate risk nursing diagnosis? -Risk for infection, as manifested by lack of client -knowledge of wound care -Risk for fatigue related to increased job demands, as manifested by feelings of exhaustion and frequent naps -Risk for altered respiratory function related to environmental allergens, as manifested by asthma -Risk for violence related to history of overt, aggressive acts

Risk for violence related to history of overt, aggressive acts

A nurse is teaching a client newly diagnosed with diabetes about diet and the exchange list. After several teaching sessions, the client continues to be confused and not sure about what to eat. The nurse's next best action is which of the following? -Get another nurse to teach the client. -Schedule a dietary consult. -Ask why the client cannot understand the information. -Nothing--hopefully, the client will understand once home and in comfortable surroundings.

Schedule a dietary consult.

After completing the diagnostic reasoning process, the nurse documents a wellness diagnosis. Which of the following would the nurse have most likely identified? -Strengths -Potential weaknesses -Potential complication -Abnormal findings

Strengths

A nurse is caring for a hospitalized client undergoing a thoracentesis at the bedside. The nurse explains to the client that the health care provider will insert a needle to remove fluid from the pleural space of the lung. After the procedure, the client reports shortness of breath. What is the best action of the nurse? -The nurse should reinforce the dressing. -The nurse should perform a focused respiratory assessment. -The nurse should notify the critical assessment team. -The nurse should notify the health care provider.

The nurse should perform a focused respiratory assessment.

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 client will have multi-system problems. -The quality of the data may be low. -The client will have a long problems list. -Clinical information can be interpreted subjectively.

The quality of the data may be low.

Which of the following statements is true of nursing diagnoses? -They encompass psychological rather than physiological problems. -They focus on the responses of clients to health problems and events. -They are less specific but more holistic than medical diagnoses. -They are rooted in subjective rather than objective data.

They focus on the responses of clients to health problems and events.

After collecting subjective and objective data for the admission database, what is the nurse's next action? -Evaluate effectiveness of nursing actions. -Validate the client's identified problems. -Set nurse-driven goals for the client. -Discuss the action plan with the client.

Validate the client's identified problems.

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 -Knowledge deficit related to lack of information regarding low-sodium diet -Anxiety related to ineffective coping during hospitalization -Ineffective health maintenance related to having last mammogram 2 years ago

Weight gain of 3 pounds (1.5 kilograms) over 1-2 days

The nurse notes the diagnosis "Readiness for enhanced coping" written on a client's care plan. What type of diagnosis has been identified for the client? -Syndrome -Wellness -Actual -Risk

Wellness

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? -Collaborative problem -Referral to dietitian -Risk diagnosis -Wellness diagnosis

Wellness diagnosis

When the client is in a state of harmony and balance, which of the following most likely would be appropriate? -Actual nursing diagnosis -Risk nursing diagnosis -Wellness nursing diagnosis -Collaborative problem

Wellness nursing diagnosis

Prior to administering medications, the nurse reviews a client's vital signs. What actual client concern will require collaborative care? -a client who is a marathon runner with a heart rate of 55 beats/min (normal range 60-100 beats/min) -a client diagnosed with pneumonia whose oxygen saturation is 95% on 1-liter nasal cannula (normal range 95%-100%), previously 93% on 2 liters -a client with a respiratory rate of 18 breaths/min (normal range 12-20 breaths/min) who walked with physical therapy around the unit -a client reporting a new onset headache and visual changes who has a blood pressure of 170/98 mm Hg (normal range 90-120/60-80 mm Hg)

a client reporting a new onset headache and visual changes who has a blood pressure of 170/98 mm Hg (normal range 90-120/60-80 mm Hg)

A nursing student demonstrates understanding of the different types of nursing diagnoses when choosing which of the following to be an actual diagnosis? -risk for impaired skin integrity -risk for infection -impaired skin integrity -readiness for enhanced skin integrity

impaired skin integrity

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

implementation

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

intuition

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 organization -nursing rationale -nursing intervention

nursing diagnosis

A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to -obtain an insufficient number of cues and cluster patterns. -formulate too many nursing diagnoses for the client and family. -include too much data about the client in the history. -quickly make a diagnosis without hypothesizing several diagnoses.

quickly make a diagnosis without hypothesizing several diagnoses.

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. -experience -seeing things as only right or wrong -knowledge -time -practice

seeing things as only right or wrong

The nurse collects data from a client with a nonproductive cough and labored respirations at a rate of 24/minute. What other data should the nurse collect before formulating an appropriate nursing diagnosis? -history of illness -rash on face -status of breath sounds -list of present medications

status of breath sounds

The nurse realizes that after she confirms that the cluster data collected meet the characteristics of a certain diagnosis, the next step is to do which of the following? -re-assess the client -cluster more data -collect more data -tell the client what you perceive the diagnosis to be

tell the client what you perceive the diagnosis to be

The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following? -reliable data -valid data -cues available to support the diagnosis -too many or too few data

too many or too few data

One characteristic of a nurse who is a critical thinker is the ability to -form an opinion quickly -validate information and judgments. -offer advice to clients. -be right most of the time.

validate information and judgments.

A nurse understands that the identified strengths found during the assessment of a client are used for which of the following nursing diagnoses? -wellness diagnosis -actual diagnosis -risk diagnosis -potential strengths diagnosis

wellness diagnosis

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the client has the opportunity for an enhanced health state: -actual diagnosis -medical diagnosis -risk diagnosis -wellness diagnosis

wellness diagnosis