Unit 2, Chapter 15, 16, 17, 18, 19 & 20 - Critical Thinking & the Nursing Process

Evaluate the success of achieving a goal.

) Evaluative measures- assessment skills and techniques (observations, physiological measurements, use of measurement scales, patient interview) (more on pg 271)

data base

a comprehensive collection of related data organized for convenient access

Describe the implementation process.

) Implementation formally begins after you develop a plan of care. A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Preparation for implementation ensures efficient, safe, and effective nursing care. Five preparatory activities are reassessing the patient, reviewing and revisiting the existing nursing care plan, organizing resources and care delivery, anticipating and preventing complications and implementing nursing interventions. (pg 261)

List the five methods to obtain data.

1. The patient through the interview, observation, and physical examination 2. Family members, or significant others report and response to interview 3. Other members from the health care team 4. Medical record information 5. Scientific and medical literature

The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function labs are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a. Diagnosis b. Planning c. Implementation d. Evaluation

ANS: A After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions. The evaluation phase involves determining whether the interventions were effective.

The following statements are on a patient's nursing care plan. Which of the following statements is written as an outcome? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased mobility in 2 days. c. The patient will demonstrate increased tolerance to activity over the next month. d. The patient will understand needed dietary changes by discharge.

ANS: A An expected outcome is a specific and measurable change that is expected as a result of nursing care. The other three options in this question are goals. Demonstrating increased mobility in 2 days and understanding necessary dietary changes by discharge are short-term goals because they are expected to occur in less than a week. Demonstrating increased tolerance to activity over a month-long period is a long-term goal because it is expected to occur over a longer period of time.

Which scenario best illustrates the use of data validation when making an independent nursing clinical decision? a. The nurse determines that she needs to remove a wound dressing when the patient reveals the time of the last dressing change, and she notices that the present dressing is saturated with fresh and old blood. b. The nurse administers pain medicine due at 1700 at 1600 because the patient complains of increased pain. c. The nurse removes a leg cast when the patient complains of decreased mobility. d. The nurse administers potassium when a patient complains of leg cramps.

ANS: A Changing the wound dressing is the only independent nursing action given. The nurse validates what the patient says with her own observation of the dressing. This option is the only assessment option as well that involves data validation. Administering pain medicine or potassium and removing a leg cast are examples of nursing interventions.

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs? a. Concept mapping b. Reflective journaling c. Reading assignment with a written summary d. Lecture and discussion

ANS: A Concept maps challenge the student to synthesize data and identify relationships between nursing diagnoses. Reflective journaling involves thinking back to clarify concepts. Reading assignments and lecture do not best provide an instructor the ability to evaluate students' abilities to synthesize data.

1. Critical thinking characteristics include a. Considering what is important in a given situation. b. Accepting one, established way to provide patient care. c. Making decisions based on intuition. d. Being able to read and follow physician's orders.

ANS: A Critical thinking involves being able to decipher what is relevant and important in a given situation and to make a clinical decision based on that importance. Patient care can be provided in many ways. Clinical decisions should be based on evidence and research. Following physician's orders is not considered a critical thinking skill.

The critical thinking skill of evaluation in nursing practice can be best described as a. Examining the meaning of data. b. Reviewing the effectiveness of nursing actions. c. Supporting findings and conclusions. d. Searching for links between data and the nurse's assumptions.

ANS: B Reviewing the effectiveness of interventions best describes evaluation. Examining the meaning of data is inference. Supporting findings and conclusions provides explanations. Searching for links between the data and the nurse's assumptions describes analysis.

Which of these findings, when evaluating another nurse developing a plan of care, should the charge nurse recognize as a source of diagnostic error? a. Assigning diagnoses while completing the database b. Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous antibiotics c. Completing the interview before performing the physical examination d. Documenting cultural and religious preferences

ANS: A Diagnosis should take place only after the database is completed. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview before the physical examination is appropriate. The patient's cultural background and developmental stage are important to include in a patient database.

The process of using assessment data gathered about a patient combined with critical thinking to explain a nursing diagnosis is known as a. Diagnostic reasoning. b. Defining characteristics. c. Assigning clinical criteria. d. Diagnostic labeling.

ANS: A Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Clinical criteria are objective signs or subjective symptoms. Diagnostic labeling is simply assigning the diagnosis.

The nurse is assessing a patient with a hearing deficit. Where is the best place to conduct this interview? a. The patient's room with the door closed b. The waiting area with the television turned off c. The patient's room before administration of pain medication d. The patient's room while the occupational therapist is working on leg exercises

ANS: A Distractions should be eliminated as much as possible when interviewing a patient with a hearing deficit. The best place to conduct this interview is in the patient's room with the door closed. The waiting area does not provide privacy. Pain can sometimes inhibit someone's ability to concentrate, so before pain medication is administered is not advisable. It is best for the patient to be as comfortable as possible when conducting an interview. Assessing a patient while another member of the health care team is working would be distracting and is not the best time for assessment to take place.

After completing a thorough assessment to formulate a patient database, the nurse should proceed to which step of the nursing process? a. Diagnosis b. Planning c. Implementation d. Evaluation

ANS: A Following assessment, analyzing the data and assigning a nursing diagnosis is the next step in the nursing process. Planning occurs after assigning the problem to establish goals. Nursing interventions are carried out in the implementation phase. The evaluation phase occurs after intervening to establish whether interventions have been effective in helping the patient meet his/her goals.

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether he has any complaints or a history of heart problems. The nurse is utilizing which critical thinking skill? a. Interpretation b. Evaluation c. Self-regulation d. Explanation

ANS: A Interpretation involves being orderly in data collection, looking for patterns to categorize data, and clarifying uncertain data. This nurse is clarifying the data in this situation. Evaluation involves determining the effectiveness of interventions. The nurse in this scenario is assessing the patient, not evaluating interventions. Self-regulation is reflecting on experiences. Explanation is supporting findings and conclusions. The nurse in this question is clarifying uncertain data (determining cause of the low pulse), not supporting the finding of a low pulse.

Subjective data include a. A patient's feelings, perceptions, and reported symptoms. b. A description of the patient's behavior. c. Observations of a patient's health status. d. Measurements of a patient's health status.

ANS: A Subjective data include the patient's feelings, perceptions, and reported symptoms. Only patients provide subjective data relevant to their health condition. Data sometimes reflect physiological changes, which you further explore through objective data collection. Describing the patient's behavior, observations made, and measurements of a patient's health status are all examples of objective data.

The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse a. Completes a comprehensive database. b. Identifies pertinent nursing diagnoses. c. Intervenes based on patient goals and priorities of care. d. Determines whether outcomes have been achieved.

ANS: A The assessment phase of the nursing process involves data collection to complete a thorough patient database. Identifying nursing diagnoses occurs during the diagnosis phase. The nurse carries out interventions during the implementation phase, and determining whether outcomes have been achieved takes place during the evaluation phase of the nursing process.

A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention? a. "Do you feel like you need to use the bathroom?" b. "Are you able to walk to the bathroom by yourself?" c. "When was the last time you took your medicine?" d. "Do you have a safety rail in your bathroom at home?"

ANS: A The nurse must establish that the patient feels the urge and is unable to void. The question "Do you feel like you need to use the bathroom?" is the most appropriate to ask. This question can be answered without knowledge of the diagnosis of Urinary retention. Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues, not to retention of urine. Taking certain medications may lead to urinary retention, but that information would establish the etiology. The question is asking for the nurse to first establish the correct diagnosis.

Which of the following are examples of subjective data? (Select all that apply.) a. Patient describing excitement about discharge b. Patient's wound appearance c. Patient's expression of fear regarding upcoming surgery d. Patient pacing the floor while awaiting test results e. Patient's temperature

ANS: A, C Subjective data include patient's feelings, perceptions, and reported symptoms. Expressing feelings such as excitement or fear is an example of subjective data. Objective data are observations or measurements of a patient's health status. In this question, the appearance of the wound and the patient's temperature are objective data. Pacing is an observable patient behavior and is also considered objective data.

The nursing process involves which of the following steps in the clinical decision-making process? (Select all that apply.) a. Identifying patient needs b. Diagnosing the disease process c. Determining priorities of care d. Setting goals e. Performing nursing interventions f. Evaluating effectiveness of medical treatments

ANS: A, C, D, E Diagnosing disease is not a nursing action. Evaluating the effectiveness of medical treatments is not a nursing action either. Nurses are to use the nursing process to evaluate the effectiveness of nursing interventions, not medical treatments. Identifying patient needs, determining priorities of care, setting realistic goals, and implementing nursing interventions are all steps in the clinical decision-making process.

Which diagnosis below is NANDA-I approved? a. Sleep disorder b. Acute pain c. Sore throat d. High blood pressure

ANS: B Acute pain is the only NANDA-I-approved diagnosis listed. Sleep disorder and high blood pressure (hypertension) are medical diagnoses, and sore throat is a subjective complaint.

After setting the agenda during a patient-centered interview, what will the nurse do? a. Begin by introducing himself. b. Conduct a nursing health history. c. Explain that the interview will be over in a few more minutes. d. Tell the patient that he'll be back to administer medications in 1 hour.

ANS: B After setting the agenda, the nurse should conduct the actual interview and proceed with data collection. Setting the stage begins with introductions and takes place before an agenda is set. The termination phase includes telling the patient when the interview is nearing an end. Telling the patient medications will be given later when the nurse returns would typically take place during the termination phase of the interview.

Which of these patient scenarios is most indicative of critical thinking? a. Administering pain relief medication according to what was given last shift b. Asking a patient what pain relief methods, pharmacological and non-pharmacological, have worked in the past c. Offering pain relief medication based on physician orders d. Explaining to the patient that his reports of severe pain are not consistent with the minor procedure that was performed

ANS: B Asking the patient what pain relief methods have worked in the past is an example of exploring many options for pain relief. Administering medication based on a previous assessment is not practicing according to standards of care. The nurse is to conduct an assessment each shift on his/her patient and intervene accordingly. Nonpharmacological pain relief methods are available, as are medications for pain. Pain is subjective. The nurse should offer pain relief methods based on the patient's reports without being judgmental.

Which of these selections is an etiology for Acute pain versus a defining characteristic? a. Complaint of pain as a 7 on a 0 to 10 scale b. Disruption of tissue integrity c. Dull headache d. Discomfort while changing position

ANS: B Disruption of tissue integrity is a possible cause or etiology of pain. A complaint of pain, headache, and discomfort are examples of things a patient might say (subjective data or defining characteristics) that lead a nurse to select Acute pain as a nursing diagnosis.

A new nurse is pulled from the surgical unit to work on the oncology unit. The nurse displays the critical thinking attitudes of humility and responsibility by a. Refusing the assignment. b. Asking for an orientation to the unit. c. Assuming that patient care will be the same as on the other units. d. Admitting lack of knowledge and going home.

ANS: B Humility and responsibility are displayed when the nurse realizes lack of knowledge and requests an orientation to the unit. The other answer choices represent inappropriate actions in this situation and are not examples of humility and responsibility. The nurse should explore all options before refusing an assignment. The nurse should not make assumptions. Assuming is not an example of critical thinking. Admitting lack of knowledge is an example of humility, but going home does not illustrate an example of responsibility.

After completing a thorough database and analyzing the data to identify any problems, the nurse should proceed to what step of the nursing process? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: B In the five-step nursing process, the nurse should establish mutual goals with the patient and prioritize care in the planning phase, which follows the diagnosis phase. The assessment phase of the nursing process involves gathering data. The implementation phase involves carrying out appropriate nursing interventions. During the evaluation phase, the nurse assesses the effectiveness of interventions.

The nursing student can best develop critical thinking skills by doing which of the following? a. Studying 3 hours more each night b. Actively participating in all clinical experiences c. Interviewing staff nurses about their nursing experiences d. Attending all open skills lab opportunities

ANS: B Nursing is an applied science, and to apply knowledge learned and develop critical thinking skills to make clinical decisions, the student should actively participate in all clinical experiences. Studying for longer hours, interviewing nurses, and attending skills labs do not provide opportunities for clinical decision making, as do actual clinical experiences.

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. This nurse should a. Notify the physician to recommend a psychological evaluation. b. Consider cultural differences during this assessment. c. Ask the patient to make eye contact to determine her affect. d. Continue with the interview and document that the patient is depressed.

ANS: B Older women of Asian descent consider it rude to look an authority figure, such as a health care professional, in the eye. This nurse needs to practice culturally competent care and appreciate the cultural differences. Assuming that the patient is depressed or in need of a psychological evaluation is inappropriate.

Professional nurses are responsible for making clinical decisions to a. Prove traditional methods of providing nursing care to patients. b. Take immediate action when a patient's condition worsens. c. Apply clear textbook solutions to patients' problems. d. Formulate standardized care plans for groups of patients.

ANS: B Professional nurses are responsible for making clinical decisions to take immediate action when a patient's condition worsens. Patient care should be based on evidence-based practice, not on tradition. Clear textbooks solutions to patient problems are not always available. Care plans should be individualized.

A patient of Middle Eastern descent has lost 5 lbs during hospitalization and states that the food offered is not allowed in his diet owing to religious preferences. Based on this information, an appropriate nursing diagnostic statement is Imbalanced nutrition: less than body requirements related to a. Religious preferences. b. Decreased oral intake. c. Weight loss. d. Race and ethnicity.

ANS: B The cause or related to factor in this case is the patient's lack of oral intake due to lack of appropriate food choices. The patient's religious preferences, race, and ethnicity did not cause his weight loss. Ultimately, the lack of food choices and his decreased intake caused him to lose weight. Weight loss is a sign of imbalanced nutrition, not a cause. The weight loss would be noticed during the assessment and would lead to the nursing diagnosis, not in reverse order.

A patient continues to report post-surgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explain to the patient that nothing else has been ordered. b. Explore other options for pain relief. c. Offer to notify the health care provider after morning rounds are completed. d. Discuss the surgical procedure and reason for the pain.

ANS: B The critically thinking nurse should explore all options for pain relief first. The nurse should use critical thinking to determine the cause of the pain and determine various options for pain, not just ordered pain medications. The nurse can act independently to determine all options for pain relief and does not have to wait until after the health care provider rounds are completed. Explaining the cause of the pain does not address options for pain relief.

The charge nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate to bathroom. The nurse needs to revise which part of the diagnostic statement? a. Nursing diagnosis b. Etiology c. Patient chief complaint d. Defining characteristic

ANS: B The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate. The patient's chief complaint is what the patient subjectively states is the problem. No subjective data are included in the diagnostic statement. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility.

Which of these questions would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a. "What types of foods do you think caused your upset stomach?" b. "How many bowel movements a day have you had?" c. "Are you able to get to the bathroom in time?" d. "What medications are you currently taking?"

ANS: B The nurse needs to first ensure that the symptoms support the diagnosis. By definition, diarrhea means that a patient is having frequent stools. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate. Asking the patient if he can make it to the bathroom will help to establish a diagnosis of incontinence, not diarrhea. The question is asking for the most appropriate statement to establish the diagnosis of Diarrhea.

While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most appropriate nursing action is to first a. Leave the room and place the patient in isolation. b. Ask the patient to describe the type of reaction. c. Proceed to the termination phase of the interview. d. Document the latex allergy on the medication administration record.

ANS: B The nurse should further assess and ask the patient to describe the type of reaction. The patient will not need to be placed in isolation; before terminating the interview or documenting the allergy, health care personnel need to be aware of what type of response the patient suffered.

Which of these findings, if identified in a plan of care, should the registered nurse revise because it is not characteristic of critical thinking and the nursing process? a. Patient's reactions to diagnostic testing b. Nurse's assumptions about hospital discharge c. Identification of five different nursing diagnoses d. Documentation of patient's ability to cope with loss

ANS: B The nurse should not assume when a patient is going to be discharged and document this information in a plan of care. Making assumptions is not an example of a critical thinking skill. The patient's reactions to testing, having several nursing diagnoses, and a description of the patient's coping abilities are all appropriate to document in the nursing plan of care.

When evaluating a plan of care, the nurse reviews the goals for the patient. Which goal statement is realistic to assign to a patient with a pelvic fracture on bed rest? The patient will increase mobility by a. Ambulating in the hallway two times this shift. b. Turning side to back to side with assistance every 2 hours. c. Using the walker correctly to ambulate to the bathroom as needed. d. Using a sliding board correctly to transfer to the bedside commode as needed.

ANS: B The patient is ordered to be on bed rest; therefore turning the patient in bed is the only option that is appropriate. When determining goals, the nurse needs to ensure that the goal is individualized and realistic for the patient.

The nurse is attempting to prompt the patient to elaborate on her complaints of daytime fatigue. Which question should the nurse ask? a. "Is there anything that you are stressed about right now?" b. "What reasons do you think are contributing to your fatigue?" c. "What are your normal work hours?" d. "Are you sleeping 8 hours a night?"

ANS: B The question asking the patient what factors might be contributing to her fatigue will elicit the best open-ended response. Asking whether the patient is stressed and asking if the patient is sleeping 8 hours a night are closed-ended questions eliciting simple yes or no responses. Asking about normal works hours will elicit a matter-of-fact response and does not prompt the patient to elaborate on her complaints of daytime fatigue nor ask about the contributing reasons.

The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, complaints of shortness of breath when getting out of bed, and a productive cough. What are the defining characteristics for the diagnostic label of Activity intolerance? a. Decreased oral intake and decreased oxygen saturation when ambulating b. Decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed c. Complaints of shortness of breath when getting out of bed and a productive cough d. Productive cough and decreased oral intake

ANS: B The signs and symptoms, or defining characteristics, for the diagnosis Activity intolerance include decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed. The key to supporting the diagnosis of Activity intolerance is that only these two characteristics involve how the patient tolerates activity.

One purpose of using standard formal nursing diagnoses in practice is to a. Form a language that can be encoded only by nurses. b. Distinguish the nurse's role from the physician's role. c. Allow for the communication of patient needs to assistive personnel. d. Help nurses focus on the scope of medical practice.

ANS: B The standard formal nursing diagnosis serves several purposes. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patient's needs. Nursing diagnoses allow nurses to communicate what they do among themselves, with other health care professionals, and the public. Nursing diagnoses distinguish the nurse's role from that of the physician, and help nurses focus on the scope of nursing practice while fostering the development of nursing knowledge.

A nursing student is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which of the following actions made by the nursing student requires the nursing professor to intervene? a. The nursing student is making eye contact with the patient. b. The nursing student is speaking only to the patient's daughter. c. The nursing student nods periodically while the patient is speaking. d. The nursing student leans forward while talking with the patient.

ANS: B When assessing an older adult, nurses need to listen carefully and allow the patient to speak. Positive nonverbal communication, such as making eye contact, nodding, and leaning forward, shows interest in the patient. Gathering data from family members is acceptable, but when a patient is able to interact, nurses need to include information from the older adult to complete the assessment.

When planning patient care, a goal can be described as a. A statement describing the patient's accomplishments without a time restriction. b. A realistic statement predicting any negative responses to treatments. c. A broad statement describing a desired change in patient behavior. d. An identified long-term nursing diagnosis.

ANS: C A goal is a broad statement that describes a desired change in a patient's condition or behavior. A goal is mutually set with the patient and is time-limited, patient-centered, measurable, and realistic.

Which of the following methods of data collection is utilized to establish a patient's nursing database? a. Reviewing the current literature to determine evidence-based nursing actions b. Orders for diagnostic and laboratory tests c. Physical examination d. Anticipated medications to be ordered

ANS: C A nursing database includes a physical examination. Orders are included in the order section of the patient's chart. The nurse reviews the current literature in the implementation phase of the nursing process to determine evidence-based actions, and the health care provider is responsible for ordering medications. Medication orders are usually written after the database is completed.

A nurse using the problem-oriented approach to data collection will first a. Complete an observational overview. b. Disregard cues and complete the database questions in chronological order. c. Focus on the patient's presenting situation. d. Make accurate interpretations of the data.

ANS: C A problem-oriented approach focuses on the patient's current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection.

To gather information about a patient's home and work surroundings, the nurse will need to utilize which method of data collection? a. Carefully review lab results. b. Conduct the physical assessment before collecting subjective information. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview.

ANS: C A thorough nursing history includes information about the patient's home and work surroundings. Neither lab results nor the physical assessment will reveal much about the home and work surroundings. Collecting data is part of the working phase of the interview.

Identify the defining characteristics in the nursing diagnosis statement: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and complaints of abdominal pain. a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention d. Constipation

ANS: C Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation is the identified problem derived from the defining characteristics.

Which of the following demonstrates a nurse utilizing self-reflection to improve clinical decision making? a. Uses an objective approach in all situations b. Obtains data in an orderly fashion c. Improves a plan of care while thinking back on interventions performed d. Provides evidence-based explanations for all nursing interventions

ANS: C Self-reflection utilizes critical thinking when thinking back on the effectiveness of interventions and how they were performed. The other options are not the best examples of self-reflection but do represent good nursing practice. Using an objective approach and obtaining data in an orderly fashion does not involve purposefully thinking back to discover the meaning or purpose of a situation. Providing evidence-based explanations for nursing interventions does not always involve thinking back to discover the meaning of a situation.

A patient expresses fear of going home and being alone. Her vital signs are stable and her incision is nearly completely healed. The nurse can infer from the subjective data that a. The patient can now perform the dressing changes herself. b. The patient can begin retaking all her previous medications. c. The patient is apprehensive about discharge. d. Surgery was not successful.

ANS: C Subjective data include expressions of fear of going home and being alone. These data indicate that the patient is apprehensive about discharge. Expressing fear is not an appropriate sign that a patient is able to perform dressing changes independently. An order from a health care provider is required before a patient is taught to resume previous medications. The nurse cannot infer that surgery was not successful if the incision is nearly completely healed.

While caring for a hospitalized older adult female post hip surgery, the new graduate nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. The nurse exhibits critical thinking to perform this task by a. Following textbook procedure. b. Notifying the physician of the need for a urologist consult. c. Adapting the positioning technique to the situation. d. Postponing catheter insertion until the next shift.

ANS: C The nurse must use critical thinking skills in this situation to adapt positioning technique. In practice, patient procedures are not always presented as in a textbook, but they are individualized. A urologist consult is not warranted for position, but perhaps instead for difficulty in insertion. Postponing insertion of the catheter is not an appropriate action.

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. The nurse should revise the plan of care first by a. Asking physical therapy to assist the patient because of the new injuries. b. Disregarding all previous diagnoses and establishing a new plan of care. c. Reassessing the patient. d. Setting new priorities for the patient.

ANS: C The nurse needs to reassess the patient after any type of change in health status. The nursing process is dynamic and ongoing. Asking physical therapy to assist the patient is premature before reassessing the patient and awaiting physician orders. The nurse may not need to disregard all previous diagnoses. Some diagnoses may still apply, but the patient needs to be reassessed first. Setting new priorities is not recommended before assessment and establishing diagnoses.

After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make? a. Administer scheduled medications assuming she would have been informed if the vital signs were abnormal. b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. c. Ask the nursing assistant to record the patient's vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress.

ANS: C The nurse should ask the nursing assistant to record the vital signs for review before administering medicines or transporting the patient to another department. The nurse should not make assumptions when providing high-quality patient care, and omitting the vital signs is not an appropriate action.

The nurse enters a room to find the patient sitting up in bed crying. How would the nurse display a critical thinking attitude in this situation? a. Tell the patient she'll be back in 30 minutes. b. Set a box of tissues at the patient's bedside before leaving the room. c. Ask the patient why she is crying. d. Limit visitors while the patient is upset.

ANS: C The nurse should try to find out why the patient is crying to intervene appropriately. Telling the patient that she will return, providing tissues, and limiting visitors may be appropriate actions but do not address the reason why the patient is crying.

Which nursing diagnostic statement is accurately written for a patient with a medical diagnosis of pneumonia? a. Risk for infection related to lower lobe infiltrate b. Risk for deficient fluid volume related to dehydration c. Impaired gas exchange related to alveolar-capillary membrane changes d. Ineffective breathing pattern related to pneumonia

ANS: C The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process of pneumonia that the nurse can treat. The related to factors lower lobe infiltrate, dehydration, and pneumonia are all medical diagnoses that the nurse cannot change. Lower lobe infiltrate is simply another term for pneumonia, a medical diagnosis. The related to factor should be the cause of the problem (nursing diagnosis) that a nurse can address.

A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. After analyzing these data, the nurse assigns which of the following nursing diagnoses? a. Adult failure to thrive b. Hypothermia c. Deficient fluid volume d. Nausea

ANS: C The signs the patient is exhibiting are consistent with dehydration. Even without knowing the clinical manifestations of dehydration, the question can be answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are not appropriate diagnoses because data are insufficient to support these diagnoses.

Professional standards influence a nurse's clinical decisions by a. Bypassing the patient's feelings to promote ethical standards. b. Establishing minimal passing standards for testing. c. Requiring the nurse to use critical thinking for the highest level of quality nursing care. d. Utilizing evidence-based practice based on nurses' needs.

ANS: C Upholding professional standards requires nurses to use critical thinking for the highest level of quality nursing care. Bypassing the patient's feelings is not practicing according to professional standards. The primary purpose of professional standards is not to establish minimal passing standards for testing. Patient care should be based on patient needs, not on nurses' needs.

A nurse comparing data validation and data interpretation correctly explains the difference with which statement? a. "Validation involves looking for patterns in professional standards." b. "Data interpretation involves discovering patterns in professional standards." c. "Validation involves comparing data with other sources for accuracy." d. "Data interpretation occurs before data validation."

ANS: C Validation, by definition, involves comparing data with other sources for accuracy. Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. The nurse should validate data before interpreting the data and making inferences. The nurse is interpreting and validating patient data, not professional standards.

Which patient outcome statement includes all seven guidelines for writing goal and outcome statements? a. The patient will ambulate in hallways. b. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort. c. The nurse will monitor the patient's heart rhythm continuously this shift. d. The patient will feed self at all mealtimes today without complaints of shortness of breath.

ANS: D A goal or outcome statement should be patient-centered; should address one patient response; should be observable, measurable, and time-limited; should be mutually set by nurse and patient; and should be realistic. The statement "The patient will feed self at all mealtimes today without complaints of shortness of breath" includes all seven criteria for goal writing. "The patient will ambulate in hallways" is missing a time limit. Administering pain medication and monitoring the patient's heart rhythm are nursing interventions; they do not reflect patient behaviors or actions.

What is the first component of the critical thinking model for clinical decision making? a. Experience b. Nursing process c. Attitude d. A scientific knowledge base

ANS: D A scientific knowledge base is the first component for clinical decision making. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. A critical thinking attitude is a guideline for how to approach a problem and apply knowledge to make a clinical decision.

A patient presents to the emergency department following a motor vehicle crash and suffers from a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and complains only of moderate discomfort. What is the most pertinent nursing diagnosis to be included in the plan of care based on the assessment data provided? a. Posttrauma syndrome b. Constipation c. Urinary retention d. Acute pain

ANS: D Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is "Complains of moderate discomfort," which would support Acute pain. No supportive evidence is provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other problems, but supportive data are presently lacking in the provided information.

Components of a nursing health history include a. Current treatment orders. b. Nurse's concerns. c. Nurse's goals for the patient. d. Patient expectations.

ANS: D Components of a nursing health history include physical examination findings, patient expectations, environmental history, and diagnostic data. Current treatment orders are located under the Orders section in the patient's chart and are not a part of the nursing health history. Patient concerns, not nurse's concerns, are included in the database. Goals that are mutually established, not nurse's goals, are part of the nursing care plan.

A nurse who is caring for a patient with a pressure ulcer fails to apply the recommended dressing according to hospital policy. If the patient is harmed, the nurse could be subject to legal action for not adhering to a. Fairness. b. Intellectual standards. c. Independent reasoning. d. Institutional practice guidelines.

ANS: D Institutional practice guidelines are established standards and policies that can be used in court to make judgments about nursing actions. Intellectual standards are guidelines or principles for rational thought. Fairness and independent reasoning are two examples of critical thinking attitudes that are designed to help nurses make clinical decisions.

A nursing assessment for a patient with a spinal cord injury leads to several pertinent problems that a nurse can treat. While developing the plan of care, which nursing diagnosis is the highest priority for this patient? a. Risk for impaired skin integrity b. Risk for infection c. Spiritual distress d. Reflex urinary incontinence

ANS: D Reflex urinary incontinence is highest priority. If a patient's incontinence is not addressed, then the patient is at higher risk of impaired skin integrity and infection. Remember that the Risk for diagnoses are potential problems. They may be prioritized higher in some cases, but not in this situation. Spiritual distress is an actual diagnosis, but the adverse effects that could result from not assisting the patient with urinary elimination take priority in this case. Physiological problems do not always take priority, but the greatest harm could come to this patient if urinary incontinence is not prioritized.

The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). The nurse is performing what type of assessment approach in this situation? a. Comprehensive assessment using Gordon's Functional Health Patterns b. General to specific assessment c. Activity-exercise pattern assessment d. Problem-oriented assessment

ANS: D The nurse is not doing a complete, general assessment and then focusing on specific problem areas. Instead, the nurse focuses immediately on the problem at hand and performs a problem-oriented assessment. Utilizing Gordon's Functional Health Patterns is an example of a structured database-type assessment technique. The nurse in this question is performing a specific problem-oriented assessment approach. The nurse is not performing an activity-exercise pattern assessment in this question.

While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this complaint, thinking that no correlation has been noted between having a leg cast and developing restless sleep. A more theoretically sound approach would be to first a. Document the sleep patterns and complaint in the patient's chart. b. Tell the patient you are just focused on the leg right now. c. Explain that a more thorough assessment will be needed next shift. d. Ask the patient about his usual sleep patterns and the onset of having difficulty resting.

ANS: D The nurse must use critical thinking skills in this situation to assess first in this situation. The best response is to gather more assessment data by asking the patient about usual sleep patterns and the onset of having difficulty resting. The nurse should assess before documenting and should not ignore the patient's complaints.

A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's best action in response to her observation? a. Proceed to the next patient's room while making rounds. b. Offer a massage because the patient does not want any more pain medicine. c. Administer the pain medication ordered for moderate to severe pain. d. Ask the patient about the facial grimacing with movement.

ANS: D The nurse needs to clarify what she observes with what the patient states. Proceeding to the next room is ignoring this visual cue. The nurse cannot assume the patient does not want pain medicine just because he rates his pain level at 2 out of 10. The nurse should not administer medication for moderate to severe pain if it is not necessary.

A patient with a spinal cord injury is seeking to enhance his urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nursing diagnosis Readiness for enhanced urinary elimination is which type of diagnosis? a. Actual b. Risk c. Health promotion d. Wellness

ANS: D The patient's desire is to increase his specific level of wellness to a higher level of wellness. An actual diagnosis describes human responses to health conditions or life processes that exist. A risk diagnosis describes human responses to health conditions/life processes that will possibly develop. A health promotion diagnosis is a clinical judgment of a patient's motivation and desire to enhance well-being and does not require a current level of wellness.

A new graduate nurse is not sure what the heart sound is that she is listening to on a patient. To avoid diagnostic error, what should the nurse do? a. Assign the nursing diagnosis of Decreased cardiac output. b. Ask the patient if he has a history of cardiac problems before assigning the diagnosis ofDecisional conflict. c. Check the previous shift's assessment and document what was noted on the last shift. d. Ask a more experienced nurse to listen also.

ANS: D The potential diagnostic error here is an error in data collection. If a new nurse is not comfortable with his/her assessment technique, he or she should ask another nurse to validate the findings. Diagnosing before validating assessment findings leads to the potential for error. Assessment data are not sufficient to assign the diagnoses Decreased cardiac output and Decisional conflict. Every nurse needs to perform his or her own assessment. A patient's status can change very rapidly. A nurse who copies the previous shift's assessment is not practicing according to standards of practice and is violating the code of ethics.

The nurse needs a reminder of professional responsibility when performing which of these actions? a. Making an informed clinical decision b. Making an ethical clinical decision c. Making a clinical decision in the patient's best interest d. Making a clinical decision based on previous shift assessments

ANS: D The professional nurse is responsible for assessing patients each shift. Making informed, ethical decisions in the patient's best interest is practicing responsibly.

A new graduate nurse will make the best clinical decisions by applying the components of the nursing critical thinking model and which of the following? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process

ANS: D Using the nursing process along with applying components of the nursing critical thinking model will help the new graduate nurse make the most appropriate clinical decisions. Care plans should be individualized, and recalling facts does not utilize critical thinking skills to make clinical decisions. The new nurse should not rely on the charge nurse to determine priorities of care.

The nurse is caring for seven patients this shift. After completing their assessments, the nurse states that he doesn't know where to begin in developing care plans for these patients. Which of the following is an appropriate suggestion by another nurse? a. "Choose all the interventions and perform them in order of time needed for each one." b. "Make sure you identify the scientific rationale for each intervention first." c. "Decide on goals and outcomes you have chosen for the patients." d. "Begin with the highest priority diagnoses, then select appropriate interventions."

ANS: D When developing a plan of care, the nurse needs to rank the nursing diagnoses in order of priority, then select appropriate interventions. Choosing all the interventions should take place after ranking of the diagnoses, and interventions should be prioritized by patient needs, not just by time. The chosen interventions should be evidence-based with scientific rationales, but the diagnoses need to be prioritized first to prioritize interventions. Goals for a patient should be mutually set, not just chosen by the nurse.

Describe the process of developing a nursing diagnosis.

Assess patient's health status validate data with other sources are additional data needed? (reassess the top) interpret and analyze meaning of data data clustering/care mapping (group s/s, classify and organize) look for defining characteristics and related factors identify patient needs formulate nursing diagnosis and collaborate problems

Describe five steps of the nursing process.

Assessment (gather information about the patient's condition), Diagnosis (identify the patients problem) Planning (set goals of care and desired outcomes and identify appropriate nursing actions) Implementation (perform the nursing actions identified in planning) Evaluation (determine if goals and expected outcomes are achieved)

standing orders

document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities

Describe how the nursing diagnosis is used in patient plan of care.

Diagnoses directs the planning process and the selection of nursing interventions to achieve a desired outcome for patients. Just a medical diagnosis of diabetes leads a health care provider to prescribe a low carb diet and medication for BS control, the nursing diagnosis directs a nurse to apply a support surface to a patients bed and initiate a turning schedule. (More on pg 237)

data

evidence; information gathered from observations

Describe the process for care plan revision, i.e., discontinuing, modifying.

Discontinuing: after you determine that your patient met expected outcomes and goals, confirm your evaluations with your patient when possible if the patient agrees you discontinue that part of the care plan. Modifying a care plan: when patients do not meet goals and outcomes you identify the factors that interfere with their achievements. (pg 275)

nursing process

five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating

counseling

giving guidance, assisting with problem solving

Differentiate between a nursing diagnosis and a medical diagnosis.

Medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs and symptoms, patient's medical history and the results of diagnostic test and procedures. A nursing diagnosis is a clinical judgment concerning a human response to health conditions/ life processes, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat; NANDA; problem focused, risk for or health promotion; Problem, etiology, symptoms (PES)

Recognize the relationship between the nursing process and critical thinking.

Experience - previous patient care experience, validation of assessment findings, observation of assessment techniques. Attitudes - perseverance, fairness, integrity, confidence, creativity, curiosity. Standards - ANA scope and standards of nursing practice, specialty standards of practice, intellectual standard of measurement. Knowledge - understanding disease process, normal growth and development, normal assessment findings, heath promotion, assessment skills, communication skills. pg. 211)

Identify characteristics of a critical thinker.

Fair-Mindedness, Autonomy, Perseverance, Integrity, Creativity, Humility, Confidence

A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing himself with two hands on the water fountain. Which critical thinking attitude is utilized in this situation? a. Humility b. Confidence c. Risk taking d. Creativity

NS: D The nurse uses creativity in this situation to figure out how the patient can stabilize himself while getting a drink of water. Humility is recognizing when more information is needed to make a decision. Confidence is being well prepared to perform nursing care safely. This question best illustrates the attitude of creativity. Risk taking is demonstrating the courage to speak out or to question orders based on the nurse's own knowledge base.

preventative nursing actions

Nursing actions directed toward preventing illness and promoting health to avoid the need for primary, secondary, or tertiary health care.

Compare scientific problem solving and nursing process.

Nursing process- a systematic problem solving approach toward providing individualized nursing care. Scientific problem solving- systematic, 7-step process, used most correctly in a scientific controlled research setting, but is closely related to problem solving in healthcare.

Describe the components of a nursing history.

Patient health history includes physical and developmental, intellectual, spiritual, emotional, and social. (pg 218)

defining characteristics

Related signs and symptoms or clusters of data that support the nursing diagnosis.

Describe how you use Maslow's hierarchy to set priorities.

See what stage they are in and set goals appropriate to age group and Maslow's group. (Using the Maslow's hierarchy chart)

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistant then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The nursing assistant states she was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked and it has dropped even lower. The nurse first made an error in what phase of the nursing process? a. Assessment b. Diagnosis c. Planning d. Evaluation

The diagnostic process should flow from the assessment. Without a thorough assessment, the nurse is more apt to misdiagnose a patient's responses, and the wrong interventions may be implemented. In this case, the nurse should have assessed the patient's blood pressure before giving the medication. The nurse could have prevented the patient's untoward reaction if the low blood pressure was assessed first. The nurse could have notified the physician, held the medication, or taken other steps to prevent an adverse reaction.

Define evaluation as the fifth step of the nursing process.

You conduct evaluative measures to determine if your patient met expected outcomes, not if nursing interventions were completed. (pg 270)

Explain the guidelines for writing goals and expected outcomes.

USE SMART for writing goals. S-specific M-Measurable A-achievable R-realistic T-time frame.

nursing interventions

activity performed by nurses that should promote the achievement of the desired patient outcome

etiology

cause of disease

nursing diagnosis

describes a health problem that can be treated by nursing measures; a step in the nursing process

Describe the process used to select nursing interventions.

desired patient outcomes, characteristics of nursing diagnosis, research base, feasibility, acceptability to patient, capability of nurse. (page 247 box 18.1)

subjective data

information perceived only by the affected person; patient's verbal description of their health problems

objective data

information that is seen, heard, felt, or smelled by an observer; signs; observations or measurements of a patient's health status

teaching

interactive process that promotes learning

activities of daily living (ADLs)

personal daily care tasks, including bathing, skin, nail, and hair care, walking, eating and drinking, mouth care, dressing, transferring, and toileting

protocol

procedure; code of behavior

nursing assessment

systematic and continuous collection and analysis of information about the patient; focus on the patient's response to health problems

Critical thinking

thinking that does not blindly accept arguments and conclusions. Rather, it examines assumptions, discerns hidden values, evaluates evidence, and assesses conclusions.