Critical Thinking and the Nursing Practice

A client in a cardiac rehabilitation program says to the nurse, "I have to eat a low-sodium diet for the rest of my life, and I hate it!" Which is the most appropriate response by the nurse? "I will get a dietary consult to talk to you before next week." "What do you think is so difficult about following a low-sodium diet?" "At least you survived a heart attack and are able to return to work." "You may not need to follow a low-sodium diet for as long as you think."

"What do you think is so difficult about following a low-sodium diet?" information from the client in order to respond directly to the client's statement. Option 1 passes off the client's educational needs to another practitioner. Options 3 and 4 are nontherapeutic.

A coworker asserts: "men always seem to exaggerate pain," the nurse who is thinking critically might ask: "Where did you read that?" "Who told you that?" "What evidence do you have for that?" "How many male patients have you had?"

"What evidence do you have for that?" Objective: Discuss the skills and attitudes of critical thinking. Rationale: The importance of critical thinking is valued in nursing. Skills to hone critical thinking can be obtained through education and experience. Answers 1, 2, and 4 are merely asking for further information.

When an elderly client brings up the possibility of entering a nursing home, the nurse who is critically thinking may ask: "Who suggested a nursing home to you?" "Why are you considering a nursing home?" "Which nursing home are you considering?" "What is bothering you?"

"Why are you considering a nursing home?" Objective: Discuss the relationships among the nursing process, critical thinking, the problem-solving process, and the decision-making process. Rationale: The nurse who is using critical thinking is able to suspend judgment and individualize care. The nurse is assuming the individual is planning for the future. In Answer 1 the nurse is assuming that someone else is trying to plan for the client's future residence. In Answer 3, the nurse is assuming that a decision already has been made. In answer 4, the client may not be bothered by anything, and the nurse is making an assumption.

The novice nurse can best demonstrate critical thinking by: Asking lots of questions Admitting uncertainty about how to do a particular procedure and asking for assistance Reading about the procedure in the Policy and Procedure Manual Relying on what she has seen other nurses do in this situation

Admitting uncertainty about how to do a particular procedure and asking for assistance Objective: Describe the significance of developing critical thinking abilities in order to practice safe, effective, and professional nursing care. Rationale: The critical thinker has an awareness of her own level of knowledge. Asking questions does not acknowledge uncertainty. Reading about the procedure in the Policy and Procedure Manual is not acknowledging uncertainty. Relying on what she has seen other nurses do in this situation is not critical thinking, because the other situations may have some variations that the novice nurse may not be aware.

What are 7 critical thinking skills?

Analyzing Applying Standards Discriminating Information Seeking Logical Reasoning Predicting Transforming Knowledge

When applying critical thinking to the assessment phase of the nursing process, the nurse will: Ask culturally sensitive questions Keep goals for the client in mind while interviewing the client Continue to clarify with the client what the nurse has planned Ask only open-ended questions

Ask culturally sensitive questions Objective: Explore ways of demonstrating critical thinking. Rationale: The assessment phase requires the nurse to gather as much data as possible in a manner that is culturally sensitive. Data will be more complete if the nurse is culturally aware and sensitive. Setting goals comes after assessment is complete. Implementation comes after goals are established. Some questions are appropriate close ended as well as open ended.

When a new policy that forbids nurses from carrying tape in their pockets is introduced, the nurse demonstrates intellectual courage by: Suggesting that the new policy might be based on flawed research Stating that there must be a mistake Attacking the new policy Asking for the rationale for the new policy

Asking for the rationale for the new policy Objective: Describe the significance of developing critical thinking abilities in order to practice safe, effective, and professional nursing care. Rationale: Intellectual courage requires the nurse to examine all sides of an issue or idea or policy. The nurse suspends judgment and is willing to consider the rationale for the policy change. The nurse who thinks critically does not jump to conclusions. In Answer 2, the nurse is not willing to consider other possibilities and is not displaying intellectual courage. In attacking the new policy, the nurse is not willing to consider the rationale for the policy change and is not displaying intellectual courage.

A client reports feeling hungry, but does not eat when food is served. Using critical thinking skills, the nurse should perform which of the following? Assess why the client is not ingesting the food provided. Continue to leave the food at the bedside until the client is hungry enough to eat. Notify the primary care provider that tube feeding may be indicated soon. Believe the client is not really hungry.

Assess why the client is not ingesting the food provided. Rationale: The nurse recognizes that many assumptions (beliefs) could interfere with the client eating—such as that the food presented is not culturally appropriate. These assumptions must be clarified. Options 2 and 3 reach conclusions not supported by the facts. In option 4, the nurse has made a judgment or has an opinion that may not be accurate. Also, the nurse is acting without assessment. Implementation should be preceded by assessment.

What are some nursing actions in the assessment phase of the nursing process?

Assess: obtain health history, conduct physical assessment, review client records, review nursing literature consult support persons, consult health professionals, update/organize/validate/communicate/document data

What is an opinion?

Beliefs formed over time; include judgments that may fit facts or be in error.Ex. Nursing intervention can assist in maintaining the clients's blood pressure within normal limits.

What is a fact?

Can be verified through investigation. Ex. Blood pressure is affected by blood volume.

When a 4-year old child refuses to take a medication in pill form because it is "too big and it hurts when I swallow," the nurse demonstrates critical thinking by: Asking the mother how she gets him to cooperate Allowing the child to skip a dose this one time and documenting the reason why Asking the nurse-manager what to do Checking with the pharmacy to see if the medication can be dispensed in liquid form

Checking with the pharmacy to see if the medication can be dispensed in liquid form Objective: Describe the significance of developing critical thinking abilities in order to practice safe, effective, and professional nursing care. Rationale: Part of critical thinking is being creative in approaches to difficult situations. Asking the mother how she gets him to cooperate may be helpful, but is not using critical thinking. It is never correct for the nurse to allow the child to skip a dose. Asking the nurse-manager what to do may be helpful, but it is not critical thinking.

What is an inference?

Conclusions drawn from the facts, going beyond facts to make a statement about something not currently known. EX. If blood volume is decreased the blood pressure will drop.

One nurse expresses that the manager prepared the holiday work schedule unfairly. The manager states that it is the same type of schedule used in the past and other nurses have no problems with it. Which response indicates the nurse is displaying an attitude of critical thinking? Accepting the preferences of the other nurses since there are several of them Recognizing that the nurse must have reached a false conclusion Considering going to a higher authority than the manager for an explanation Continuing to query the manager until the nurse understands the explanation

Continuing to query the manager until the nurse understands the explanation Rationale: The critical thinking approach should include perseverance until a reasonable solution or answer is determined. Giving in (option 1), overquestioning self, poor trust in one's own beliefs (option 2), or bypassing normal routes of authority (option 3) violates the desirable attitudes of integrity, intellectual courage, and confidence in reason.

When the nurse considers that a client is from a developing country and may have a positive tuberculosis test due to a prior vaccination, which critical thinking attitude and skill is the nurse practicing? Creating environments that support critical thinking Tolerating dissonance and ambiguity Self-assessment Seeking situations where good thinking is practiced

Creating environments that support critical thinking Rationale: Nurses must embrace exploration of the perspectives of persons from different ages, cultures, religions, socioeconomic levels, and family structures to create environments that support critical thinking. Option 2 relates to nurses who should increase their tolerance for ideas that contradict previously held beliefs. Option 3 is conducted when a nurse benefits from a rigorous personal assessment to determine which attitudes he or she already possesses and which need to be cultivated. Option 4 occurs when nurses find it valuable to attend conferences in clinical or educational settings that support open examination of all sides of issues and respect for opposing viewpoints.

The nurse knows that the nursing diagnosis of Fluid Volume Excess may be related to altered circulation or an electrolyte imbalance. As a result, the nurse reviews lab results and checks the blood pressure and ankles for swelling in a client who recently had cardiac surgery. What kind of reasoning is the nurse using? Inductive Deductive Scientific method Intuition

Deductive Objective: Discuss the skills and attitudes of critical thinking. Rationale: When the nurse begins with knowledge of a nursing diagnosis, it is in keeping with deductive reasoning to look for specific data to support that diagnosis. Inductive is starting with the data and forming a generalization, opposite of what the nurse is doing in this case. Scientific method is not related to the reasoning the nurse is doing with respect to the nursing process. Intuition is a "gut feeling," and is not related to the reasoning the nurse is doing with respect to nursing process.

When inductive reasoning is applied to the research process, the nurse expects to: Develop a theory from the research results Identify appropriate theories to test during the research Propose one or more hypotheses prior to initiating the research study Develop one or more hypotheses at the conclusion of the study

Develop a theory from the research results Objective: Discuss the relationships among the nursing process, critical thinking, the problem-solving process, and the decision-making process. Rationale: When using inductive reasoning, the nurse expects to form generalizations from facts or observations. The nurse expects to take isolated data and develop a theory. Identifying appropriate theories to test during the research is deductive reasoning. Proposing one or more hypotheses prior to initiating the research study is not a generalization. Hypotheses are formed prior to beginning a study.

What are some nursing actions in the diagnosing phase of the nursing process?

Diagnose: compare data against standards, cluster or group data, identify gaps and inconsistencies, determine client's strengths, risks, diagnoses, and problems; formulate nursing diagnoses and collaborative problem statements; document nursing diagnoses on the care plan

What are some nursing actions in the evaluation phase of the nursing process?

Evaluate: collaborate with client and collect data related to desired outcomes, judge whether goals/outcomes have been achieved, relate nursing actions to client outcomes, make decisions about problem status, review and modify the care plan as indicated or terminate nursing care, document achievement of outcomes and modification of the care plan.

What is a judgment?

Evaluation of facts or information that reflect values or other criteria; a type of opinion. EX. It is harmful to the client's health if the blood pressure drops too low.

In the decision-making process, the nurse sets and weights the criteria, examines alternatives, and performs which of the following before implementing the plan? Reexamines the purpose for making the decision Consults the client and family members to determine their view of the criteria Identifies and considers various means for reaching the outcomes Determines the logical course of action should intervening problems arise

Identifies and considers various means for reaching the outcomes Rationale: It is important to project what problems might interfere with the plan and have appropriate responses prepared to prevent the interferences. The purpose for the decision should have been clear enough at the outset as to not require reexamination at this point (option 1). Clients and families should be consulted early—in the purpose-setting and criteria-setting steps. Criteria should not be set until all significant participants have an opportunity to present their point of view (option 2). Considering various means for reaching the outcomes is the same as examining alternatives (option 3).

A client with diarrhea also has a primary care provider's order for a bulk laxative daily. The nurse, not realizing that bulk laxatives can help solidify certain types of diarrhea, concludes, "The primary care provider does not know the client has diarrhea." This statement is an example of: A fact. An inference. A judgment. An opinion.

Inference The nurse has inferred and concluded something that is beyond the available information (and in this case may not be accurate). The prescription and the diarrhea are facts (option 1). It would be judgment and opinion if the nurse stated that the laxative would make the diarrhea worse and should not be given (options 3 and 4). (Note: Critical thinking will cause this nurse to examine the assumptions made and gather more data before acting.)

The nurse is teaching a client about wound care during a follow-up visit in the client's home. Which critical thinking attitude causes the nurse to reconsider the plan and supports evidence-based practice when the client states, "I just don't know how I can afford these dressings"? Integrity Intellectual humility Confidence Independence

Integrity Rationale: By reconsidering the type of dressing used based on research, the nurse is using integrity. Options 2 and 3 are critical thinking attitudes characterized by an awareness of the limits of one's own knowledge, and being trustworthy. Option 4 indicates an attitude of not being easily swayed by the opinions of others.

After examining her client's abdomen and finding it firm and round, even though the client says it doesn't hurt, the nurse says to a colleague, "I think something is going on here; I am going to check the latest assessment." This nurse is using: Deductive reasoning Intuition Trial and error Modified scientific method

Intuition Objective: Discuss the relationships among the nursing process, critical thinking, the problem-solving process, and the decision-making process. Rationale: Intuition is the "gut feeling" one has without the conscious use of reasoning. Deductive reasoning is reasoning from the general to the specific. Trial and error is a problem-solving process that requires trying one or more approaches until one works. Modified scientific method is a logical, systematic approach to problem solving that the nurse is not using in this case.

The nurse is concerned about a client who begins to breathe very rapidly. Which action by the nurse reflects critical thinking? Notify the primary care provider. Obtain vital signs and oxygen saturation. Request a chest x-ray. Call the rapid response team.

Obtain vital signs and oxygen saturation. Rationale: The nurse's intuition is like a sixth sense that allows the nurse to recognize cues and patterns to reach correct conclusions. The nurse appropriately obtains vital signs and an oxygen saturation to assess the client's clinical picture more fully. Option 1 supports appropriate nursing actions, but the client's respiratory status should be assessed first. Usually, a physician must order a chest x-ray (option 2). The rapid response team (option 4) may be needed if the client's condition becomes more critical.

What are some nursing actions in the planning phase of the nursing process?

Plan: set priorities and goals/outcomes in collaboration with client, write goals/desired outcomes, select nursing strategies/interventions, consult other health professionals, write nursing orders and nursing care plan, communicate care plan to relevant healthcare providers.

Which reasoning process describes the nurse's actions when the nurse evaluates possible solutions for care of an infected wound for optimal client outcomes? Intuition Research process Trial and error Problem solving

Problem solving Rationale:Anurse thinks critically, evaluates possible solutions, and uses problem solving. Intuition (option 1) is not a sufficient basis for implementing wound care when significant data on alternative care strategies are available. Research (option 2) is a more comprehensive rigorous process and not typically implemented while caring for an infected wound. Trial and error (option 3) is unsafe and inappropriate for care of an infected wound.

The client who is short of breath benefits from the head of the bed being elevated. Because this position can result in skin breakdown in the sacral area, the nurse decides to study the amount of sacral pressure occurring in other positions. This decision is an example of The research method. The trial-and-error method. Intuition. The nursing process.

The research method. Rationale: The research method uses a research study-based approach to problem solving. Trial and error (option 2) and intuition (option 3) would involve unstructured approaches resulting in less predictable results. The nursing process generally uses application of known interventions, previously determined by the scientific (research) process (option 4).

Intuition

The understanding or learning of things without conscious use of reasoning, nurses are able to judge quickly which evidence is most important and to act on that limited evidence.

A client who is in pain refuses to be repositioned. In making a decision about what to do, what should the nurse consider first? Why a decision is needed When a decision is needed Who actually gets to make the decision What are the alternatives

Why a decision is needed Objective: Discuss the relationships among the nursing process, critical thinking, the problem-solving process, and the decision-making process. Rationale: Decision making requires the nurse to select the best action to meet a desired goal. When a decision is needed comes after determining why a decision is needed. Who actually makes the decision is important, but not the first thing to consider. What the alternatives are comes after determining why a decision is needed, who makes the decision, and when a decision is needed.

What are the five components of nursing process?

a. Assessing b. Diagnosing c. Planning d. Implementing e. Evaluating

Why is critical thinking important?

a. Essential to safe, competent, skillful nursing practice b. Rapid and continuing growth of knowledge c. Make complex and important decisions d. Draw meaningful information from other subject areas e. Work in rapidly changing, stressful environments f. Recognize important cues, respond quickly, and adapt interventions

How does one develop critical thinking attitudes & skill?

a. Self-assessment, analysis of thinking process and attitudes, tolerating dissonance and ambiguity, seeking situations where good thinking is practiced, creating environments that support critical thinking, attendance at conferences.

What is creativity and why is it important in nursing?

a. Thinking that results in the development of new ideas and products; the ability to develop and implement new and better solution b. Important when nurse encounters a new situation or a client situation in which traditional interventions are not effective

Deductive reasoning

by contrast, is reasoning from the general premise to the specific conclusion. Example: nurse who uses the needs framework might categorize data and define the client's problem in terms of elimination, nutrition, or protection needs

What are some nursing actions in the implementation phase of the nursing process?

d. Implement: reassess the client to update the database, determine need for nursing assistance, perform planned nursing interventions, communicate what nursing actions were implemented (document care and client responses to care, give verbal reports as necessary)

Inductive reasoning

generalizations are formed from a set of facts or observations.Example: nurse who observes that a client has dry skin, poor turgor, sunken eyes, and dark amber urine may make the generalization that the client appears dehydrated

Trial and error

in which a number of approaches are tried until a solution is found.

Nursing process

is a systematic, rational method of planning and providing individualized nursing care. The phases of the nursing process are assessing, diagnosing, planning, implanting, and evaluating.

Socratic questioning

is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes.

Concept mapping

is a technique that uses a graphic depiction of nonlinear and linear relationships to represent critical thinking.

Critical thinking

is an intentional higher level reasoning process that is intellectually delineated by ones worldview, knowledge, and experience with skills, attitudes, and standards as a guide for rational judgment and action.

Critical analysis

is the application of a set of questions to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas.

Creativity

is thinking that results the development of new ideas and products. Problem solving and decision making is the ability to develop and implement new and better solutions for health care outcomes.

Decision making

nurses use critical thinking in decision making to help them choose the best action to meet desired goal.

Problem solving

the nurse obtains information that clarifies the nature of the problem and suggests possible solutions and chooses the best one to implement.