Nursing Fundamentals-Chapter 13

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 Accuracy Precision Relevance

Clarity

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? Planning Diagnosis Implementation Assessment

Diagnosis

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 Supervisory Technical Maintenance Surveillance

supervisory

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. applies intuition and routine care for clients. employs communication to meet the client's needs. uses scientific problem solving to meet client problems.

uses critical thinking to direct care for the individual client.

When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply. A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. All plans of care are the same for clients with certain medical diagnoses. Only the client is involved in outcome setting, not the family. Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care.

A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care. Outcome setting and planning should be comprehensive and ongoing, occurring in all phases of care. The plan of care should always be individualized (not the same for a group of clients with the same medical diagnosis), and setting outcomes helps to individualize a plan of care. Long- and short-term outcomes should be included in the plan of care. Clients and their families should be involved in the creation.

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? Nutrition Activity and rest Health promotion Self-perception

Activity and Rest

The nurse is caring for an underweight female 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? -Weigh client as needed. -Administer a high-calorie diet, excluding wheat, rye, and oats. -Monitor for allergies. -Administer a daily multivitamin.

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. Persistent when delivering care to all clients to complete all measures during a shift Responsible and accountable for own actions Overly sensitive so that problems are addressed in a timely fashion Inflexible when it comes to the care of the client to ensure that the client meets the desired outcome Alert to context so that the need for modification can be identified and changes to the plan of care can be made

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 Explanation:

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 diagnosis. -Follow up with the client later to determine whether the client's laboratory test results improve. -Identify outcomes for the client with the client's input. -Administer a prescribed medication to decrease the client's blood glucose level.

Analyze the data and create an individualized nursing diagnosis.

A nurse technician is assigned to take clients' vital signs. When making rounds, the nurse notices that one client's vital signs are very different from what they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings? Ask the nurse technician whether the vital signs are correct. Assess the client's vital signs again. Call the health care practitioner for new orders. Document the vital signs in the client's chart.

Assess the client's vital signs again.

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: objective data. nursing diagnosis. intervention. outcome.

Assessment

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 Planning Implementation Diagnosis

Assessment

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? Assessment Planning Implementation Evaluation

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 -Recognizing that the client's blood pressure of 172/101 is an abnormal finding - Taking a client's blood pressure on both arms at the beginning of a shift - Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading

Checking the client's blood pressure 30 minutes after administering captopril

Which action exemplifies the purpose of evaluation in the nursing process? Determine the client's health status, self-care ability, and need for nursing. Develop a prioritized list of nursing diagnoses. Decide whether to continue, modify, or terminate client care. Develop an individualized plan of client care.

Decide whether to continue, modify, or terminate client care.

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? Check the client's skin turgor. Formulate a plan of care based on risk for dehydration. Administer an additional liter of intravenous fluids. Determine whether the prescribed treatment was effective.

Determine whether the prescribed treatment was effective.

A hospital client has an aggressive fungal infection in the right eye that necessitates evisceration (removal of the eye). Consequently, the client requires twice-daily packing and dressing changes to the orbit. Which of the nurse's actions in the care of this client most clearly demonstrates interpersonal skills? Ensuring the client's privacy during dressing changes and providing an explanation during the procedure Documenting the condition of the client's orbit and the procedure of the dressing change in an accurate and timely manner Understanding the anatomy and physiology of the affected parts of the client's body Maintaining aseptic technique when performing the dressing change

Ensuring the client's privacy during dressing changes and providing an explanation during the procedure

The nurse assesses a client's blood pressure, which is 160/90 mm Hg. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure, finding it to be 140/78 mm Hg. Which action has the nurse implemented? Planning Appraising Implementing Evaluating

Evaluating

The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should the nurse determine this phase will include? Select all that apply The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care. Evaluation does not involve client assessment. Only factors that positively affect the outcome should be identified during evaluation. Evaluations should be documented daily in the client's record. Evaluation is the last part of the nursing process.

Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.

On a particular 12-hour day shift, the nurse-client ratio on a busy floor is lower than usual because a member of the health care team called in sick for the day. Which example shows this nurse practicing with a good sense of legal competence in response to this challenge? - To save time, the nurse asks an experienced coworker what the safe dosage of a medication for a client would be rather than look it up. - The nurse leaves some tasks that cannot be completed during the day shift for the night shift, including the 4 pm labs. - Following the chain of command, the nurse requests help completing the tasks essential to client care that day. - Instead of documenting every 2 hours per hospital protocol, the nurse documents a detailed shift assessment and an end-of-shift note to cover what has happened during the shift.

Following the chain of command, the nurse requests help completing the tasks essential to client care that day.

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. 1 Identify the data 2 Collect assessment data 3 Formulate a hypothesis 4 Make a plan for action 5 Evaluate

Identify the data Collect assessment data Formulate a hypothesis Make a plan for action Evaluate

Which statements are true about the implementation phase of the nursing process? Select all that apply. Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health. Implementation is only carried out by nursing professionals. Care provided during implementation should be documented in the client's chart. All interventions carried out during this phase must be accompanied by a physician's order.

Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health. Care provided during implementation should be documented in the client's chart.

Which statement best conveys the role of intuition in nurses' problem solving? Intuition can be a clinically useful adjunct to logical problem solving. Intuition is an unreliable mode of thinking that should be avoided. In experienced nurses, intuition can be a valid replacement for scientific problem solving. Intuition is reliable when those nurses implementing it have a special "gift."

Intuition can be a clinically useful adjunct to logical problem solving.

Which are characteristics of reasoning? Select all that apply. Is based on assumptions Has a purpose Lacks a point of view Contains inferences Has implications

Is based on assumptions Has a purpose Contains inferences Has implications All reasoning: has a purpose; is an attempt to figure something out, to settle some question, to solve some problem; is based on assumptions; is done from some point of view; is based on data, information, and evidence; is expressed through, and shaped by, concepts and ideas; contains inferences or interpretations by which we give meaning to data; and leads somewhere or has implications and consequences.

Which statement regarding critical thinking in nursing is true? It supplies validation for reimbursement. It is a systematic way of thinking. It makes judgments based on conjecture. It shows trends and patterns in client status.

It is a systematic way of thinking.

Which is the most appropriate example of the assessment phase of the nursing process? Documenting the administration of a medication provided for pain Evaluating the temperature of a client given medication for a fever Including a nursing diagnosis of Acute Pain in the client's plan of care Palpating a mass in the right lower quadrant of the abdomen

Palpating a mass in the right lower quadrant of the abdomen

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? -Diagnosing; implementing -Assessing; diagnosing -Implementing; evaluation - Planning; implementing

Planning; implementing

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? Add a new nursing diagnosis in the nurse's own words to individualize the plan of care. Keep resolved nursing diagnoses as part of the plan of care in case the related problems return. Do not allow the client to review the client's own nursing diagnoses. Prioritize the nursing diagnoses.

Prioritize the nursing diagnoses. 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 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? During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. After turning the client alone, the nurse realizes that the nurse should have insisted on having help. The nurse decides to turn the client every 4 hours because everyone is too busy to help.

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.

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain? -Administering extra pain medication -Administering a placebo -Documenting opioid dependence -Repositioning the client

Repositioning the client

Which statement is true of the nursing process? -It is a valid alternative to using intuition to respond to nursing situations. - It is more appropriate in medical surgical settings than community health care. -Scientific problem solving can occur within the nursing process. -Trial-and-error problem solving is an efficient use of the nurse's time.

Scientific problem solving can occur within the nursing process.

Put the phases of the nursing process in the correct order. Use all options. 1 planning 2 evaluation 3 diagnosis 4 implementation 5 assessment

assessment diagnosis planning implementation evaluation

Which statement regarding critical thinking in nursing is true? It is a systematic way of thinking. It shows trends and patterns in client status. It makes judgments based on conjecture. It supplies validation for reimbursement.

it is a systemic 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.

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: objective data. intervention. outcome. nursing diagnosis.

outcome

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: promoting the nurse's self-esteem. reflective practice. assessment of oneself. learning from mistakes.

reflective practice.

A nurse demonstrates critical thinking when applying the nursing process to client care. Which behavioral components would the nurse likely use during the assessment phase? Select all that apply. Recognizing assumptions Asking relevant questions Exploring ideas Recognizing issues Interpreting evidence

Asking relevant questions Exploring ideas Recognizing issues

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? Document the rash in the client's chart. Establish a nursing diagnosis of Altered Skin Integrity. Report it to the health care provider. Assess the client's back visually.

Assess the client's back visually

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: "Everyone is different so I cannot say how your body might react." "When exposed to extreme cold, the body works hard to stay warm and may warm itself 1-2 degrees above normal during exposure." "You can expect your body temperature to drop about 3 degrees during your time at the bus stop." "We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time."

"We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time."

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which action best demonstrates the nursing skill of caring in this situation? Assessing the abdominal incision Monitoring vital signs Notifying the health care provider of lab results Assisting the client to sit up in a chair

Assisting the client to sit up in a chair

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. Heart failure Pneumonia Impaired mobility Imbalanced nutrition Ineffective coping

Impaired mobility Imbalanced nutrition 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? Develop an additional nursing diagnosis to meet the client's health needs. Change the nursing diagnosis because the client's problem was falsely identified. Modify the plan of care and interventions to meet the client's needs. Reassess the client for more symptoms of deficient fluid volume.

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.

Which statements are true about informatics in nursing practice? Select all that apply. Informatics only involves documentation of timely and accurate charting. Utilization of information services helps to support decision making. Computers do not help with communication, but deter it because of the lack of personal interaction. Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error.

Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision making.

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: create an exercise plan that is realistic and valued. exercise every day for at least 30 minutes. only eat three meals per day. stop eating meat and walk every day after dinner.

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 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? Diagnosis Evaluation Planning Implementation

Planning

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes? Memorization Reflection Assessment Evaluation

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.

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? Risk for falls Hypertension Congestive heart failure Pneumonia

Risk for falls

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? -requiring the client to evaluate the plan of care after implementation -involving the client with all the steps of the process in care development -ensuring the client is informed after decisions are made with care delivery -implementing the standard plan of care for all clients with diabetes mellitus

Trial-and-error problem solving

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 Intuitive thinking Scientific problem solving Critical thinking

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.

Put the phases of the nursing process in the correct order. Use all options. 5 evaluation 4 implementation 2 diagnosis 1 assessment 3 planning

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. -expect the client to be drowsy, and let the client rest. -evaluate the abdominal dressing for drainage. -administer pain medication.

complete the postoperative assessment.

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. evaluate the abdominal dressing for drainage. administer pain medication. expect the client to be drowsy, and let the client rest.

complete the postoperative assessment.