Physical Assessment SCENERIOS Chapter 2: Critical Thinking in Health Assessment

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 used in assessment, whereas critical thinking is used in analysis."

A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?

"What other symptoms occurred during the spell?"

A nurse has selected several nursing diagnoses in the process of data analysis for a client with poorly controlled type 1 diabetes. One of these collaborative problems is altered health maintenance due to infrequent blood glucose monitoring as manifested by elevated HgA1C. How would the nurse best validate this diagnosis with the client?

"Would you agree that there's room for improvement in your routines for blood sugar monitoring?"

The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.

1. "I feel so tired sometimes." 2. "My father died of a heart attack." 3. Client complains of a headache

A nurse is preparing to document conclusions after analyzing data and includes information about related factors and manifestations. What is the nurse formulating?

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?

Analyze the data

The nurse is attempting to cluster the data collected during the initial assessment of an older adult client. The nurse notes that the client had a swollen left knee and complained of "a bit of soreness" in the joint, but the nurse does not have enough data to support a nursing diagnosis of Impaired Physical Mobility. What should the nurse do next?

Assess the client further for evidence of reduced mobility and decreased range of motion.

A home health nurse has completed an assessment on a 78-year-old widower who lives alone and is dependent on a volunteer from the local community center to bring the client one meal every day. The client states they have no appetite and "fruits and vegetables are too difficult to chew." Before identifying a client concern, what would be next best step for the nurse to take?

Check for supporting data to support a client concern.

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

Clinical reasoning process

When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?

Diagnosis

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.

A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine whether the client has achieved the outcome criteria of the treatment?

Evaluation

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?

Implementation

A hospital nurse has identified a need to improve her critical thinking skills in an effort to improve client care. The nurse should identify which of the following characteristics of critical thinking?

It involves reflections on thoughts before reaching conclusions.

Which of the following would be most important for a nurse when developing critical thinking skills?

Maintenance of an open mind

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.

Your client has been directly admitted from the doctor's office. The only paperwork he has brought with him is his admission orders. You are gathering your admission data when ordered lab work is collected. When documenting your history, physical examination, assessment, and plan, what would you write under the heading "Laboratory Data"?

None currently.

A nurse has completed data analysis. Which of the following would the nurse identify first as the result?

Nursing diagnosis

The nurse is exhibiting critical thinking in which client care situation?

Performing a focused assessment on a client who is complaining of shortness of breath.

The nurse is developing goals after completing the assessment of a newly admitted medical client. The nurse would document the goals under which part of the nursing process?

Planning

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?

Schedule a dietary consult.

Which of the following statements is true of nursing diagnoses?

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

When documenting clinical data after an assessment of the client's neck, what might you write in the physical assessment?

Thyroid isthmus barely palpable, lobes not felt

After collecting subjective and objective data for the admission database, what is the nurse's next action?

Validate the client's identified problems.

The result of a nursing assessment is the

formulation of nursing diagnoses.

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

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

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?

status of breath sounds

A nurse has admitted a client to the medical unit who has just been diagnosed with endocarditis secondary to IV drug use. The nurse has completed the collection of objective and subjective data. What question should guide the next step in the nurse's data analysis?

What are this client's strengths?

A nurse has just admitted a client who has a wound infection to the unit. After assessing the client, the next step of the nursing process the nurse should perform is:

analyze the data

The nurse is collecting data from a client. Which of the following best reflects objective data?

Appearance

An instructor is describing how to arrive at an informed clinical judgment to a group of students. The instructor is accurate when describing that the nurse will cluster supportive and abnormal cues. In which step toward making a clinical judgment will the nurse cluster the cues?

Second step

The nurse is clustering abnormal and supportive cues after the initial assessment of an older adult client. The nurse notes that the client had a swollen left knee and reported "a bit of soreness" in the joint. The nurse identifies a client concern. What should the nurse do next?

Validate the client concern with the client and family.