PrepU Chapter 13 Blended Competencies, Clinical Reasoning, and Processes of Person-Centered Care

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? A. Assessment B. Planning C. Diagnosis D. Implementation

A. Assessment

Which are characteristics of one who has developed critical thinking skills? A. Self-aware, honest, persistent, and authentic B. Creative, oriented to success, self-determined, and perfectionistic C. Curious, other-directed, fallible, and humble D. Resilient, authoritative, reactive, and private

A. Self-aware, honest, persistent, and authentic

Which intervention is most appropriate for a client newly diagnosed with diabetes and a nursing diagnosis of Deficient Knowledge? A. Teach the client how to administer insulin. B. Monitor blood glucose level before meals. C. Monitor for hypoglycemia and hyperglycemia. D. Administer insulin as prescribed.

A. Teach the client how to administer insulin.

How can the nurse obtain a more complete database for a newly admitted client? A. Analysis of lab values B. Comprehensive client assessment C. Clustering of data D. Review of the chart

B. Comprehensive client assessment

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? A. Planning B. Diagnosis C. Implementation D. Assessment

B. Diagnosis

Which step of the nursing process involves reporting or analysis of data to identify and define health problems? A. Planning B. Implementation C. Diagnosis D. Assessment

C. Diagnosis

The nurse is preparing to document the nursing diagnoses for a client. What is the most appropriate outcome for the nursing diagnosis of impaired gas exchange? A. The client will have decreased work of breathing. B. The client will maintain a respiratory rate between 12 and 20 breaths per minute. C. The client will have clear breath sounds. D. The client will maintain a pulse oximeter reading of greater than 94% (0.94 L).

D. The client will maintain a pulse oximeter reading of greater than 94% (0.94 L).

Which activity is the clearest example of the evaluation step in the nursing process? A. Taking a client's blood pressure on both arms at the beginning of a shift B. Recognizing that the client's blood pressure of 172/101 is an abnormal finding C. Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading D. Checking the client's blood pressure 30 minutes after administering captopril

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

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

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

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

D. It is a systematic way of thinking.

A nurse is providing care to an older adult client diagnosed with heart disease. The nurse uses the nursing process to provide individualized care using the actions listed below. Place the actions in the order that the nurse would most likely complete them using the nursing process. 1. Obtains the client's weight daily. 2. Obtains the client's vital signs 3. Identifies risk for fluid volume excess 4. Determines that the client's fluid balance is stabilized 5. Develops a realistic goal for monitoring fluid balance 6. Prepares an individualized strategy for addressing risk

2. Obtains the client's vital signs 3. Identifies risk for fluid volume excess 5. Develops a realistic goal for monitoring fluid balance 6. Prepares an individualized strategy for addressing risk 1. Obtains the client's weight daily. 4. Determines that the client's fluid balance is stabilized

Which step in the nursing process includes the careful taking of a history and a nursing examination? A. Assessment B. Implementation C. Nursing diagnosis D. Planning

A. Assessment

A nurse is conducting a client interview and gathers information from secondary sources. Which sources might the nurse use? Select all that apply. A. Client's children B. Client's physician C. Client's previous admission record D. Client's caregiver E. Client

A. Client's children B. Client's physician D. Client's caregiver

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

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

A. Determine whether the prescribed treatment was effective.

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 A. Evaluation is the last part of the nursing process. B. Only factors that positively affect the outcome should be identified during evaluation. C. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care. D. Evaluation does not involve client assessment. E. Evaluations should be documented daily in the client's record.

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

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

A. Outcomes can be short- and long-term. B. Outcome setting allows for individualization of the plan of care. C. A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care.

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

A. Prioritize the nursing diagnoses.

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

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

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? A. Do not document this assessment because the client could be using a wireless device to talk to family. B. Document this assessment based on the client's behaviors. C. Document that the client is talking back to the voices in the client's head. D. Do not document this assessment because it is subjective.

B. Document this assessment based on the client's behaviors.

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. A. Heart failure B. Imbalanced nutrition C. Impaired mobility D. Ineffective coping E. Pneunomia

B. Imbalanced nutrition C. Impaired mobility D. Ineffective coping

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

B. Modify the plan of care and interventions to meet the client's needs.

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? A. Implementing; evaluation B. Planning; implementing C. Assessing; diagnosing D. Diagnosing; implementing

B. Planning; implementing

Which is the best example of person-centered care provided by a registered nurse? A. Insertion of a nasogastric tube for gastric decompression B. Reassuring a client who is anxious about a procedure C. Administration of pain medication every 4 hours to a client who is postoperative D. Development of a plan of care for a new admission

B. Reassuring a client who is anxious about a procedure

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? A. Hypertension B. Risk for falls C. Congestive heart failure D. Pneumonia

B. Risk for falls

Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: A. Uses scientific problem solving to meet client problems. B. Uses critical thinking to direct care for the individual client. C. Employs communication to meet the client's needs. D. Applies intuition and routine care for clients.

B. Uses critical thinking to direct care for the individual client.

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented? A. Reflection B. Assessment C. Clinical reasoning D. Caring

C. Clinical reasoning

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: A. Only eat three meals per day. B. Stop eating meat and walk every day after dinner. C. Create an exercise plan that is realistic and valued. D. Exercise every day for at least 30 minutes.

C. Create an exercise plan that is realistic and valued.

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill? A. Interpersonal B. Visual C. Intellectual D. Technical

C. Intellectual

Which is a characteristic of person-centered care? A. It is independent of other disciplines. B. It involves general care for all clients. C. It is a framework for providing care. D. It can be used in hospital settings.

C. It is a framework for providing care.

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

C. Palpating a mass in the right lower quadrant of the abdomen

What is the most beneficial use of the nursing process in addressing the needs of the client? A. Allows student nurses to work on assignments B. Targets desired outcomes for particular illnesses, procedures, or conditions C. Provides a universally applicable framework for nursing activities D. Allows the nurse to determine a medical diagnosis for the client

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

C. Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.

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

C. Reflection

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 A. Technical B. Surveillance C. Supervisory D. Maintenance

C. Supervisory

The nurse is caring for a mother and newborn baby couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast feed. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the most appropriate action by the nurse at this time? A. Contact the lactation consultant and ask if the plan of care needs to be modified. B. Refer the couplet to a nutritionist. C. Terminate the plan of care because evaluation reveals that the outcome has been met. D. Modify the plan of care to follow-up more frequently to assure that the outcome will be met.

C. Terminate the plan of care because evaluation reveals that the outcome has been met.

Which are characteristics of a critical thinker? Select all that apply. A. Accepting the status quo B. Acting like a know-it-all C. Thinking based on the opinions of others D. Being open to all points of view E. Resisting easy answers to client problems F. Thinking outside the box

D. Being open to all points of view E. Resisting easy answers to client problems F. Thinking outside the box

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? A. Nutrition B. Health promotion C. Self-perception D. Activity and rest

D. Activity and rest

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

D. Assisting the client to sit up in a chair