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?

Assessment

Which action exemplifies the purpose of evaluation in the nursing process?

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

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. Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care.

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?

Assess the client's vital signs again.

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?

Administer a high-calorie diet, excluding wheat, rye, and oats.

A nurse is educating a pregnant client in preterm labor on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn?

Anxiety

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

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?

Determine whether the prescribed treatment was effective.

Which is an important element of implementation?

Documentation

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?

Evaluating

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.

Impaired mobility Imbalanced nutrition Ineffective coping

Which statement best conveys the role of intuition in nurses' problem solving?

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

Which is a characteristic of person-centered care?

It is a framework for providing care.

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?

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

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?

Repositioning the client

An adolescent with diabetes has a nursing diagnosis of noncompliance related to activities that interfere with the treatment plan as evidenced by elevated blood glucose levels. The outcome for this client is to maintain blood glucose levels between 70 and 110 mg/dL (3.89 and 6.11 mmol/L). The main intervention is to educate the client about the effects of abnormal blood glucose level on the body and ensure that the client has the resources to be compliant. Evaluation reveals that the client's blood glucose level remains elevated and that the outcome has not been met. What is the most appropriate action by the nurse?

Modify the plan of care to find alternative ways to meet client needs.

Which is the most appropriate example of the assessment phase of the nursing process?

Palpating a mass in the right lower quadrant of the abdomen

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?

Planning

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?

Prioritize the nursing diagnoses.

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?

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

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client.

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

Put the phases of the nursing process in the correct order. Use all options.

assessment diagnosis planning implementation evaluation

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?

involving the client with all the steps of the process in care development

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.