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 -Planning -Implementation -Diagnosis
Assessment Explanation: During assessment, the nurse recognizes the existence of cues and conducts a focused data collection. During diagnosis, the nurse clusters cues, interprets the clusters, and validates the diagnoses for accuracy. Planning involves preparing a client plan of care, which directs the activities of the nursing staff in the provision of care. Implementation is the action phase of the nursing process.
The nurse is caring for a client who has been in the hospital for 7 days. When the nurse enters the room to perform the morning assessment, the client tells the nurse that the client can't wait to go home. Which statement by the nurse demonstrates that the nurse is skilled in developing caring relationships? -"What do you miss most about being away from home?" -"Maybe you will get to go home soon." -"I am really busy this morning, but after my morning rounds I will come back and we can discuss how you feel." -"Well, you only have 3 days left before you can go home."
"What do you miss most about being away from home?" Explanation: Developing caring relationships is an essential nursing function. Nurses who are skilled in developing caring relationships create conversations that show genuine interest in the client and the client's concerns. By asking this client what the client misses most about being away from home, the nurse communicates the nurse's interest in the client's feelings and allows the client to express more about the things that the client is missing. Dismissing the client because the nurse is busy is nontherapeutic and does not show that the nurse values a caring relationship with the client. Also, stating that the client may get to go home soon or informing the client of the remainder of the client's stay also dismisses any further discussion about the client's concerns and is nontherapeutic.
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 next nursing action? -Report the rash to the health care provider. -Assess the client's back visually. -Establish a nursing concern of altered skin integrity. -Document the rash in the client's chart.
Assess the client's back visually. Explanation: Assessment is the first phase in the nursing process, so the nurse should perform a visual assessment of the client's rash before proceeding to activities that pertain to later phases, such as reporting or documenting the rash or formulating a nursing concern.
At 0730, the nurse notes that the client states that pain is a 7 on a scale of 0 to 10. Based on this assessment, the nurse administers pain medication to the client. At 0800, the nurse evaluates the client and finds that pain is a 4 on a scale of 0 to 10. Which example of documentation most clearly communicates the initial morning assessment? -0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered. -0900: Client states pain from 0730 has decreased from a 7 to a 4 after medication was administered. -0800: Client states that pain has decreased. -0730: Client states that pain is severe. Pain medication administered.
0730: Client reports pain is a 7 on a scale of 0-10. Morphine sulfate 2 mg IV administered. Explanation: Documentation using the nursing process must be accurate, timely, and relevant. In the above example, documentation at 0730 for the initial assessment is timely, it is concise when assigning a number to the client's pain level, and it is relevant to the assessment at hand and the action that the nurse took based on the assessment: pain medication administration. Documenting the client's pain as severe or decreased is not concise; a pain scale should be used. Documenting at 0900 the evaluation of the assessment and intervention is not timely.
Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)? -Grip weakness in the right hand -A blood glucose level of 108 mg/dL -Crackles in bilateral lung bases -A client report of shooting pain up the left leg
A client report of shooting pain up the left leg Explanation: Subjective data consists of information that the client can describe, also known as symptoms. Therefore, a client report of pain in the leg is an example of a subjective finding that the nurse would likely obtain when performing an ROS. A blood glucose level of 108 mg/dL, an observation of weakness in the right hand, and auscultation of crackles in bilateral lung bases are examples of objective data that the nurse or health care provider can observe and measure.
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 concern for care planning. -Identify outcomes for the client with the client's input. -Administer a prescribed medication to decrease the client's blood glucose level. -Follow up with the client later to determine whether the client's laboratory test results improve.
Analyze the data and create an individualized nursing concern for care planning. Explanation: The second part of the nursing process is the analysis of data that can help determine nursing concerns for care planning. Because the nurse has the assessment findings of polydipsia, polyphagia, polyuria, and an increased HgbA1C level, the nurse can analyze these findings to help to determine the most appropriate nursing concern. Once the nursing concern is determined, then the nurse, with input from the client, can identify outcomes and interventions, such as medication administration, implement the interventions and evaluate them.
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? -Diagnosis -Assessment -Planning -Implementation
Assessment Explanation: During assessment, the nurse recognizes the existence of cues and conducts a focused data collection. During diagnosis, the nurse clusters cues, interprets the clusters, and validates the diagnoses for accuracy. Planning involves preparing a client plan of care, which directs the activities of the nursing staff in the provision of care. Implementation is the action phase of the nursing process.
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? -Monitoring vital signs -Assisting the client to sit up in a chair -Notifying the health care provider of lab results -Assessing the abdominal incision
Assisting the client to sit up in a chair Explanation: Caring skills are nursing interventions that restore or maintain a person's health and may involve actions as simple as assisting with activities of daily living--the acts that people normally do every day, such as bathing, grooming, dressing, toileting, and eating. Assisting the client to sit up in the chair is an example of this type of caring behavior. The other options are important nursing tasks, but they are not demonstrating the art of caring.
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? -Reflection -Caring -Clinical reasoning -Assessment
Clinical reasoning Explanation: Clinical reasoning is the process of making a nursing judgment that will provide safe and quality care. Caring is holistically meeting the needs of the client. Reflection is looking back on events that have occurred and learning from them how to improve one's practice. Assessment is careful observation and evaluation of a client's health status.
Which statements are true about the implementation phase of the nursing process? Select all that apply. -This phase promotes wellness and restores health. -Implementation is the process of carrying out the plan of care. -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 health care provider's order.
Care provided during implementation should be documented in the client's chart. Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health. Explanation: The implementation phase is the phase of the nursing process in which the plan of care is carried out. It is designed to promote wellness and restore health to clients through interventions that are collaborative and nursing driven. Not all interventions included in this phase have to be accompanied by a health care provider's order. Interventions are collaborative in that more than nursing professionals are involved in restoring health to the client.
Which activity is the clearest example of the evaluation step in the nursing process? -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 -Taking a client's blood pressure on both arms at the beginning of a shift -Recognizing that the client's blood pressure of 172/101 is an abnormal finding
Checking the client's blood pressure 30 minutes after administering captopril Explanation: Measuring the client's blood pressure after performing an intervention such as drug administration determines the extent to which the client has achieved the outcome desired, which in this case is lowered blood pressure. Initially checking the client's blood pressure is an example of assessment, whereas recognizing it as an anomaly constitutes diagnosis. Administering the drug is a form of implementation.
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? -Accuracy -Precision -Relevance -Clarity
Clarity Explanation: The nurse's question reflects clarity, or the need for more information. Accuracy would be reflected in questions about the information being true. Precision is reflected by questions asking for more details or specifics. Relevance would be reflected by questions related to how something connects to the issue.
The nurse is caring for a client in a critical care unit. The client's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm? -Cognitive and technical skills -Cognitive and ethical skills -Interpersonal and technical skills -Interpersonal and ethical skills
Cognitive and technical skills Explanation: The nurse used cognitive and technical skills to interpret this cardiac rhythm. Cognitive and technical skills equip nurses to manage the clinical problems stemming from the client's changing health or illness state. Interpersonal and ethical skills are essential for concerns related to the client's broader well-being.
How can the nurse obtain a more complete database for a newly admitted client? -Analysis of lab values -Clustering of data -Comprehensive client assessment -Review of the chart
Comprehensive client assessment Explanation: By having a more complete database from several sources, including the client, the nurse can arrive at a more accurate conclusion. The nurse can obtain data from secondary sources, such as family members, significant others, other health care professionals, health records, and literature review. Clustering of data, analysis of laboratory values, and review of the chart are all done after gathering data through assessment to develop nursing diagnoses; they would not help the nurse gather more data on the client.
A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. Which behavior is the nurse demonstrating in the care of the client? -Reflection in action -Critical reflectivity -Thoughtful practice -Reflective skepticism
Critical reflectivity Explanation: Critical reflectivity (becoming aware of one's awareness and critiquing it) occurs when a person questions judgments and considers other ways of thinking about the situation. Thoughtful practice is caregiving to promote the humanity, dignity, and well-being of the client. Reflection in action requires the person to engage in exploring experiences to lead to new understandings and appreciations during the situation or during clinical practice. Reflective skepticism involves adopting an attitude of doubt about supposed truths.
Which action exemplifies the purpose of evaluation in the nursing process? -Develop a prioritized list of nursing concerns. -Determine the client's health status, self-care ability, and need for nursing. -Develop an individualized plan of client care. -Decide whether to continue, modify, or terminate client care.
Decide whether to continue, modify, or terminate client care. Explanation: Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health concerns. Outcome identification and planning specify the nursing diagnosis to the client's strengths, thereby individualizing the plan of 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? -Formulate a plan of care based on risk for dehydration. -Administer an additional liter of intravenous fluids. -Check the client's skin turgor. -Determine whether the prescribed treatment was effective.
Determine whether the prescribed treatment was effective. Explanation: The sequence of the nursing process is assessment, diagnosis, planning, implementation, and evaluation. Checking skin turgor is an assessment. Formulating a care plan is part of planning. Administration of additional fluid occurs during implementation. The nurse evaluates whether the intervention was effective, as demonstrated by a rise in blood pressure and a decline in pulse rate.
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? -Administer an additional liter of intravenous fluids. -Determine whether the prescribed treatment was effective. -Formulate a plan of care based on risk for dehydration. -Check the client's skin turgor.
Determine whether the prescribed treatment was effective. Explanation: The sequence of the nursing process is assessment, diagnosis, planning, implementation, and evaluation. Checking skin turgor is an assessment. Formulating a care plan is part of planning. Administration of additional fluid occurs during implementation. The nurse evaluates whether the intervention was effective, as demonstrated by a rise in blood pressure and a decline in pulse rate.
The nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying? -Developing technical skills -Developing ethical/legal skills -Enjoying the rewards of mutual interchange -Developing accountability
Developing accountability Explanation: Nurses committed to interpersonal caring hold themselves accountable for the human well-being of clients entrusted to their care. Being accountable means being attentive and responsive to the health care needs of individual clients, being concerned for the client in all situations, and ensuring that continuity of care is in place when leaving a client. This is not an example of technical skills. Enjoying the rewards of mutual interchange means the nurse enriches everyday interactions by investing something of themselves in the relationship with the client and, in return, receiving something from the client. Developing ethical/legal skills refers to providing client care that provides advocacy for the client while mediating ethical conflicts and following legal guidelines.
Which action should the nurse associate with outcome identification and planning in the nursing process? -Develops an individualized plan of nursing care. -Determines the client's health status, self-care ability, and need for nursing. -Develops a prioritized list of problem-based nursing concerns. -Decides whether to continue, modify, or terminate nursing care.
Develops an individualized plan of nursing care. Explanation: In the process of outcome identification and planning, the nurse adapts the identified nursing concern to address the client's strengths, thereby individualizing the plan of care. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care.
Which step of the nursing process involves reporting or analysis of data to identify and define health problems? -Planning -Implementation -Assessment -Diagnosis
Diagnosis Explanation: During the second phase of the nursing process (diagnosis), the nurse reports or analyzes data to identify and define health problems that independent or health care provider-prescribed nursing actions can prevent or solve. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care, performing interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments.
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? -Do not document this assessment because it is subjective. -Do not document this assessment because the client could be using a wireless device to talk to family. -Document that the client is talking back to the voices in the client's head. -Document this assessment based on the client's behaviors.
Document this assessment based on the client's behaviors. Explanation: Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs. Assessment should be documented accurately, completely, concisely, factually, and in a timely manner. To document factually, the nurse should document the client's behaviors, not the nurse's interpretation of the behaviors. In this situation, the nurse could and should quickly determine whether the client is using a wireless device to communicate with family and then document the client's behavior only if needed. The nurse's observation of the client talking out loud when no one else is in the room is an objective, not subjective, finding (the client reporting hearing voices in the head is an example of a subjective finding, as it is not observable by the nurse). In any case, both objective and subjective findings should be documented.
The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0 to 10. There is an order for intravenous pain medication every 4 hours as needed. The nurse administers the prescribed pain medication to the client. What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0 to 10? -Continue making rounds on other clients and let the client rest. -Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect. -Call the surgeon to report the pain level. -Modify the plan of care to include an additional pain medication because the client's pain is so severe.
Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect. Explanation: In the evaluation phase of the nursing process, the nurse measures the extent to which the client has achieved outcomes. This phase helps determine whether the nurse should terminate, continue, or modify the plan of care. To ensure that this client's plan of care is appropriate, the nurse must evaluate the client's response to the intervention of administering pain medication. The nurse must evaluate the results of the intervention that has already been implemented before determining the need to modify the plan of care. Therefore, neither calling the surgeon nor modifying the plan of care is appropriate at this time, and continuing to make rounds on other clients would not address this client's needs specifically.
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 -Implementing -Planning -Appraising
Evaluating Explanation: The nurse is collecting data to evaluate the effectiveness of a medication that was administered. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care, performing interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments. Appraising is not a discrete part of the nursing process.
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 -Evaluations should be documented daily in the client's record. -Evaluation does not involve client assessment. -Evaluation is the last part of the nursing process. -The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care. -Only factors that positively affect the outcome should be identified during evaluation.
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. Explanation: The evaluation phase, which is the last phase of the nursing process, measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. Evaluation does involve nursing assessment to determine whether the client has met the outcome. The nurse should identify both factors that positively and negatively affect the outcome to assist with meeting the client's outcomes, and evaluation findings should be documented daily in the client's record.
Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill? -Interpersonal -Intellectual -Visual -Technical
Intellectual Explanation: Teaching requires knowledge about teaching-learning principles to convey. The intellectual skills used in implementation include problem solving, decision making, and teaching.
Which statement best conveys the role of intuition in nurses' problem solving? -Intuition can be a clinically useful adjunct to logical problem solving. -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 is an unreliable mode of thinking that should be avoided.
Intuition can be a clinically useful adjunct to logical problem solving. Explanation: Creative, intuitive thinking can be useful supplements to more "in-the-box" methods of problem solving. While it should not be discouraged outright, it should also not be thought of as a replacement for logical or scientific problem solving. Intuition is not dependent on a special "gift" but is thought to be a product of experience and unconscious pattern recognition.
Which statement regarding critical thinking in nursing is true? -It makes judgments based on conjecture. -It shows trends and patterns in client status. -It is a systematic way of thinking. -It supplies validation for reimbursement.
It is a systematic way of thinking. Explanation: 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.
Which statements about the nursing process are accurate? Select all that apply. -It is essential for identifying medical diagnoses. -It is an orderly way of solving client problems. -It helps to emphasize the client's active role in making decisions. -It focuses on the care of adult clients. -It is important for providing individualized care to each client.
It is important for providing individualized care to each client. It is an orderly way of solving client problems. It helps to emphasize the client's active role in making decisions. Explanation: The nursing process is an orderly, systematic, problem-solving approach to giving individualized care. Nurses use it in all settings with clients of all ages to identify and treat human responses to potential and actual health problems, not to identify medical diagnoses. It requires the nurse to incorporate the uniqueness of each individual, leading to individualized care. The nursing process also complements the current role of consumers in health care, in which clients play an active role in decisions affecting their health.
An adolescent with diabetes has been noncompliant with activities noted in their 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 appropriate action by the nurse? -Terminate the plan of care because the client will not listen to health care providers. -Modify the plan of care to find alternative ways to meet client needs. -Reevaluate the plan of care at a later date. -Refer the client to the social worker.
Modify the plan of care to find alternative ways to meet client needs. Explanation: The evaluation phase of the nursing process measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. On evaluation, this client had not met the outcome. Therefore, the appropriate response by the nurse is to modify the plan of care to find alternative ways of meeting this client's needs. Reevaluating the plan of care at a later date does not address this client's needs in a timely fashion, nor does referring the client to the social worker. Terminating the plan of care is not appropriate if the client has not found a way to address the problems identified in the nursing care plan.
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. -Nurses should value technologies that support error prevention and care coordination. -The use of informatics can help manage knowledge and mitigate error. -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. Utilization of information services helps to support decision making. Explanation: Traditionally, documentation consisted of timely and accurate charting. However, the QSEN updated definition is expanded and calls for using information and technology to communicate, manage knowledge, mitigate error, and support decision making. Nurses should value technologies that support error prevention and care coordination.
A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care? -Clinical reasoning -Experience -Reflection -Nursing process
Nursing process Explanation: Although clinical reasoning, reflection, and experience are important components of nursing, the nursing process is recognized as the method of practicing nursing. It is the model on which professional nursing standards are based. Although it sometimes is criticized for not being adaptable to the changing health care environment, the nursing process remains the almost universally accepted method for providing nursing care.
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? -Implementation -Evaluation -Diagnosis -Planning
Planning Explanation: During the planning phase, the nurse examines alternatives and judges the worth of evidence using this information to develop the plan of care for the client. During diagnosis, the nurse analyzes the assessment information to identify actual or potential responses to health problems. During implementation, the nurse carries out the plan of care. During evaluation, the nurse determines outcome attainment, revises plans, and identifies a client's perception of results.
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? -Assessing; diagnosing -Diagnosing; implementing -Implementing; evaluation -Planning; implementing
Planning; implementing Explanation: Determining the correct length of the NG tube to insert is an example of the planning that is necessary to conduct this nursing action. The actual insertion of the NG tube would constitute implementation. Assessment would be checking that after insertion, the NG tube is properly working. Diagnosing is gathering the evidence that the client needs an NG tube. Evaluation would be determining whether the outcome associated with inserting the NG tube has been accomplished.
A nurse has developed a plan of care for an adult client. What nursing function is important when using the identified nursing concerns to guide the care of this client? -Prioritize the nursing concerns. -Do not allow the client to review the nursing concerns identified for them. -Add a new nursing concern in the nurse's own words to individualize the plan of care. -Keep resolved nursing concerns as part of the plan of care in case the related problems return.
Prioritize the nursing concerns. Explanation: After performing a nursing assessment, data should be analyzed and compiled into actual and potential health problems and documented as nursing concerns. It is the nurse's responsibility to prioritize the nursing concerns, thereby prioritizing the care of the client. Resolved nursing concerns should be deleted from the plan of care as soon as they are resolved and replaced with new ones when appropriate. Nursing concerns 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; therefore, the client should be aware of what is included.
Which is the best example of person-centered care provided by a registered nurse? -Insertion of a nasogastric tube for gastric decompression -Administration of pain medication every 4 hours to a client who is postoperative -Development of a plan of care for a new admission -Reassuring a client who is anxious about a procedure
Reassuring a client who is anxious about a procedure Explanation: Person-centered care involves consideration of a client holistically by incorporating an awareness of the client's feelings into the provision of care. Person-centered care is different from task-oriented care in that the task-oriented nurse is only focused on completing tasks in a timely manner. Reassuring a client who is anxious about a procedure shows caring in that the nurse considers the client's feelings about the procedure and does not focus only on the procedure as a task in and of itself. Administering pain medicine, development of the plan of care, and insertion of a nasogastric tube are all important tasks but are not the best example of person-centered care.
Which is the best example of person-centered care provided by a registered nurse? -Insertion of a nasogastric tube for gastric decompression -Development of a plan of care for a new admission -Administration of pain medication every 4 hours to a client who is postoperative -Reassuring a client who is anxious about a procedure
Reassuring a client who is anxious about a procedure Explanation: Person-centered care involves consideration of a client holistically by incorporating an awareness of the client's feelings into the provision of care. Person-centered care is different from task-oriented care in that the task-oriented nurse is only focused on completing tasks in a timely manner. Reassuring a client who is anxious about a procedure shows caring in that the nurse considers the client's feelings about the procedure and does not focus only on the procedure as a task in and of itself. Administering pain medicine, development of the plan of care, and insertion of a nasogastric tube are all important tasks but are not the best example of person-centered care.
The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next? -Ask the parent whether the child has been exposed to cold temperatures. -Assess the skin for signs of cyanosis. -Recheck the temperature, paying close attention to technique. -Cover the infant.
Recheck the temperature, paying close attention to technique. Explanation: Tympanic membrane thermometers are noninvasive and fast to use, but studies show discrepancies between their readings and those of oral thermometers, resulting in both false-positive and false-negative readings. The nurse can minimize these discrepancies by using the same ear and device for measurement each time and by using proper technique. The other actions listed would be appropriate for the nurse to take after rechecking the infant's temperature and confirming that it actually is lower than normal.
In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged? -Identifying a positive situation -Recalling a sequence of events -Thinking about relationships involved -Reevaluating experience in light of ideas
Reevaluating experience in light of ideas Explanation: Reflection at the higher level includes reevaluating experience in the light of ideas, behavior, feelings, and values. Reflection at the basic level includes recalling the sequence of events, identifying a positive situation, and thinking about relationships involved.
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? -After turning the client alone, the nurse realizes that the nurse should have insisted on having help. -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. -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. Explanation: 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.
Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes? -Memorization -Reflection -Assessment -Evaluation
Reflection Explanation: 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.
Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes? -Reflection -Evaluation -Assessment -Memorization
Reflection Explanation: 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 administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain? -Documenting opioid dependence -Administering extra pain medication -Administering a placebo -Repositioning the client
Repositioning the client Explanation: The nursing process focuses on the client's unique problems, setting priorities, developing goals and outcome criteria, and selecting nursing interventions. Repositioning the client is a nursing intervention; it is nonpharmacologic and does not require a prescription from the health care provider and can assist with pain relief. Administering extra pain medication may only be done with a prescription from the health care provider. Documenting opioid dependence is inappropriate and not within the nurse's scope of practice. Administering a placebo is inappropriate and unethical.
Which statement is true of the nursing process? -Trial-and-error problem solving is an efficient use of the nurse's time. -It is a valid alternative to using intuition to respond to nursing situations. -Scientific problem solving can occur within the nursing process. -It is more appropriate in medical surgical settings than community health care.
Scientific problem solving can occur within the nursing process. Explanation: Problem solving and the nursing process are not competing or mutually exclusive processes. Rather, scientific problem solving is the focus of the nursing process. One of the strengths of the nursing process is that it is applicable to all nursing areas, from medical-surgical to community health settings.
Which are characteristics of one who has developed critical thinking skills? -Curious, other-directed, fallible, and humble -Resilient, authoritative, reactive, and private -Creative, oriented to success, self-determined, and perfectionistic -Self-aware, honest, persistent, and authentic
Self-aware, honest, persistent, and authentic Explanation: The characteristics of one who has developed critical thinking skills include: self-aware, genuine/authentic, effective communicator, curious/inquisitive, confident/resilient, honest, creative, proactive, persistent, and improvement-oriented.
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. -Recognize how the approach affects client care, and describe why you have to do things your way. -Introduce yourself, and then accomplish nursing care activities efficiently to allow the client to rest. -Approach the client as part of the job, and complete nursing care quickly to promote comfort.
Show respect for the client, and engage in open communication in getting to know the client. Explanation: Respect for the client's dignity, and establishing a caring relationship, is furthered by mutual exchange of communication. Approaching care/client as a job, doing things without client input, and doing things your way and efficiently are not necessarily therapeutic, nor do they initiate communication.
Which outcome is most appropriate for the nurse to include in the care plan for a client with the identified nursing concern of infection risk? -The client takes the client's own temperature daily. -The client has a normal temperature and no signs or symptoms of infection. -The client understands what symptoms to monitor for. -The client takes the prescribed antibiotic.
The client has a normal temperature and no signs or symptoms of infection. Explanation: The evaluation phase of the nursing process measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. Evaluation related to the temperature and absence of signs of infection directly addresses the client outcome and individualizes the plan of care. Taking an antibiotic, understanding symptoms to monitor for, and/or taking the client's temperature daily do not specifically address the client outcome.
The clinical nurse manager is evaluating a new nurse who has been employed for 3 months. What type of knowledge does the manager evaluate that is required for competent clinical reasoning? Select all that apply. -The nurse understands nursing and medical terminology. -The nurse is committed to the organization's mission and values. -The nurse is able to organize and manage time efficiently. -The nurse performs skills safely and never makes a mistake. -The nurse can demonstrate basic mathematical problem solving.
The nurse is committed to the organization's mission and values. The nurse is able to organize and manage time efficiently. The nurse understands nursing and medical terminology. Explanation: Competent clinical reasoning requires many different facets of knowledge and intellectual skills. Some of them include committing to the organizational mission and values, organizing and managing one's time efficiently, and understanding nursing and medical terminology. Basic mathematical skills are not sufficient; the nurse who can clinically reason must be able to do drug calculations efficiently. Even though a priority should be safety, the nurse will occasionally make mistakes; every attempt should be made to prevent those mistakes, but they should be dealt with constructively when they do occur.
The nurse is admitting a client to the acute care unit with a diagnosis of dehydration. The client's skin turgor is poor and the mucous membranes are pale and dry. What is the rationale for the next phase in the nursing process? -To develop a prioritized list of current and possible health problems -To develop an individualized plan of client care -To determine the client's health status, self-care ability, and need for nursing. -To decide whether to continue, modify, or terminate client care
To develop a prioritized list of current and possible health problems Explanation: Given that the nurse clearly has assessed the client, the next phase in the nursing process would be diagnosis. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Outcome identification and planning specify the nursing diagnosis to the client's strengths, thereby individualizing the plan of care. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care.
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? -Intuitive thinking -Scientific problem solving -Critical thinking -Trial-and-error problem solving
Trial-and-error problem solving Explanation: 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.
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? -activity and rest -nutrition -self-perception -health promotion
activity and rest Explanation: A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertinent for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.
A nurse has completed a client assessment and is preparing to identify appropriate nursing concerns. Which area(s) will the nurse likely address in the nursing concern? Select all that apply. -pneumonia -heart failure -ineffective coping -altered mobility -altered nutrition
altered mobility altered nutrition ineffective coping Explanation: A nursing cocern is "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 concern describes an individual, family, or group response to an actual or potential health problem. A nursing concern provides the basis for selection of nursing interventions to achieve positive client outcomes.
Put the phases of the nursing process in the correct order. Use all options.
assessment diagnosis planning implementation evaluation Explanation: The correct order of the phases of the nursing process is: assessment, diagnosis, planning, implementation, and evaluation.
A nurse identifies the the nursing concern of altered skin integrity related to immobility as evidenced by reddened areas on the sacrum. The nurse is likely in which phase of the nursing process? -assessment -planning -implementation -diagnosis
diagnosis Explanation: The statement reflects a nursing concern, which provides the basis for selecting interventions to achieve positive client outcomes. Assessment involves the collection of data. Planning involves preparing a client plan of care, which directs activities of the nursing staff in provision of client care. Implementation involves the actual initiation of the plan, evaluation of the response to the plan, and recording of nursing actions and client response to the actions.
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
involving the client with all the steps of the process in care development Explanation: Because the plan of care should be client-centered, the client should be directly involved with all phases of the creation of the care plan. This will involve assessing the learning needs of the client as well as goal setting, implementation, and evaluation. The client should be involved and not just informed of decisions regarding care during the evaluation phase. The client may be involved with the evaluation but the nurse will assess to determine if the plan of care is effective and if the client's goals are being met. Standard plans of care do not address the needs of the individual and should be tailored to the individual client.
A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as: -health care equipment that has practice modes. -small, doll-like devices used for measuring vital signs. -life-sized mannequins with a sophisticated computer interface. -life-saving equipment that resuscitates clients in cardiac arrest.
life-sized mannequins with a sophisticated computer interface. Explanation: The human client simulator, a life-sized mannequin with a sophisticated computer interface, presents students with clinical scenarios that evolve based on decisions that students make. The other equipment and devices described are tools used to learn and practice skills, rather than build on critical thinking skills.
A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is newly diagnosed, the nurse included in the plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in the client? The client will: -not exhibit signs and symptoms of hypoglycemia/hyperglycemia. -log all meals in a diary for the next 6 weeks. -maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). -maintain a normal HgbA1C.
maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). Explanation: Outcomes can be short- or long-term, and short-term outcomes should describe a single, observable, and measurable behavior. Maintaining a blood sugar between 70 and 110 mg/dL (3.89 and 6.11 mmol/L) is short-term and is a single, observable, measurable outcome. Logging meals for 6 weeks and maintaining a normal HgbA1C are more long-term goals. Not exhibiting signs and symptoms of hypoglycemia/hyperglycemia is not as measurable/observable as monitoring the blood sugar.
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: -intervention. -outcome. -objective data. -nursing diagnosis.
outcome. Explanation: This statement is an outcome statement that focuses on the client, is realistic, and is measurable. The pain report is objective data; subjective data would include information from the client, such as reports of pain or anxiety. Nursing diagnosis is a clinical judgment about an individual, family, or community experience/response to an actual or potential health problem. Intervention would be the action to be completed based on the nursing diagnosis and intended outcome (e.g., administering a prescribed analgesic).
Which is the most appropriate example of the assessment phase of the nursing process? -documenting the administration of a medication provided for pain -palpating a mass in the right lower quadrant of the abdomen -including a nursing concern of acute pain in the client's plan of care -evaluating the temperature of a client given medication for a fever
palpating a mass in the right lower quadrant of the abdomen Explanation: Palpation of a mass in the abdominal cavity is an example of assessment in the nursing process through collecting data that determine the need for nursing care. Documentation of medication administration is an intervention. Evaluating the temperature of a client given medication for a fever is a better example of evaluation through assessment. Including a nursing concern in the plan of care is part of determining actual and potential health problems.
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. -learning from mistakes. -assessment of oneself.
reflective practice. Explanation: Reflective practice is the use of self-evaluation by nurses committed to quality nursing practice. Learning from mistakes and assessment of oneself is part of the reflective practice, which improves the nurse's self-esteem in caring for clients.
What type of intervention is the nurse performing when the nurse observes the spouse of a postoperative client performing the client's dressing change? -supervisory -surveillance -technical -maintenance
supervisory Explanation: The term "supervisory intervention" is applied in the context of overseeing a client's overall care.
Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: -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. -applies intuition and routine care for clients.
uses critical thinking to direct care for the individual client. Explanation: The nursing process requires blended skills and critical thinking. Critical thinkers think systematically about the nursing process and apply it for the individual client. Communication is important but not sufficient to meet client needs, and scientific problem solving is used in the laboratory setting, not nursing.
