Chapter 5: Analyzing Data to Make Informed Clinical Judgments

The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good critical thinking skills, but don't really understand what that is?" What is the best response by the preceptor?

"A way of processing information using to formulate conclusions or diagnoses."

A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The student needs further explanation when making which statement?

"All clients have the same defining characteristics."

A nursing student is explaining to a roommate the relationship between diagnostic reasoning and critical thinking. Which of the following is the correct statement for the nursing student to make?

"Diagnostic reasoning is a form of critical thinking used to interpret data correctly."

A nurse has been clustering the data collected during the initial assessment of a frail elderly client. When making inferences about the data clusters, the nurse is unsure whether to associate a cluster of data with a nursing diagnosis or with a collaborative problem. What question would best guide the nurse's decision?

"Does this issue require medical intervention?"

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.)

1. Be nonjudgmental and keep an open mind. 2. Use rationale to support opinions or decisions. 3. Acquire an adequate knowledge base that continues to build.

The nurse reviews data collected during an assessment. Which data should the nurse validate? Select all that apply.

1. Data that is inconsistent with another finding 2. Subjective and objective data are inconsistent 3. Gap between what the client said and what is in the medical record

A nurse is conducting an interview with a new client. Which of the following would the nurse identify as abnormal? Select all that apply.

1. difficulty sleeping 2. recently unemployed 3. significant unexpected weight loss

A nursing student is learning how to use critical thinking in formulating a plan of care. The student understands which of the following to be things needed to demonstrate that the process of thinking critically has begun? (Select all that apply.)

1. reserves a final opinion until further collecting data 2. explores other alternatives before making a decision 3. uses past knowledge and experience to analyze data

A community health nurse provides information to a client with newly diagnosed multiple sclerosis for a support group at the local hospital for clients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following?

A referral

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan?

Ask the client for opinions and willingness to proceed with the interventions.

A client has 3+ pitting edema, crackles in lungs, and dyspnea. The nurse is monitoring the client's vital signs and O2 saturations, and the physician has prescribed 40 mg of intravenous Furosemide (Lasix). What type of problem is this considered?

Collaborative problem

What can the nurse use to learn new information and add to their knowledge base?

Clinical experience.

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

Clinical reasoning process

The student nurse asks the instructor, "What is the difference between the data analysis and the diagnostic phase?" What is the best response by the instructor?

Data analysis is also referred to as the diagnostic phase because the end result is the identification of the nursing diagnosis."

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?

Diagnostic reasoning skills are required to interpret data accurately.

The nurse collected extensive data during a client assessment and is performing the first step in the process of data analysis. Successful completion of this step requires the nurse to do which of the following?

Differentiate between expected findings and abnormal findings.

During the assessment interview, the client made numerous statements that suggested his life generally exists in a state of harmony and balance. The nurse would document this as which type of nursing diagnosis?

Health promotion diagnosis

The nurse has identified several risk factors for a client in the hospital that has fallen. Which step of the diagnostic reasoning process is the identification of these risk factors?

Identify Abnormal Data and Strengths

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse?

Make a referral to the dietician.

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

Nursing diagnosis

A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case?

Overlooking consideration of the clients cultural background

The nursing student demonstrates a need for further teaching when she states which of the following?

Patients do not need to understand their problems.

An unlicensed assistive personnel (UAP) reports a low oxygen saturation level of 85% on a client. The nurse enters the room to find the client talking on the phone with a family member, laughing. What is the first action of the nurse?

Recheck the client's oxygen saturation.

A nurse is teaching a client newly diagnosed with diabetes about diet and the exchange list. After several teaching sessions, the client continues to be confused and not sure about what to eat. The nurse's next best action is which of the following?

Schedule a dietary consult.

A nurse working on a medical-surgical unit in a hospital reviews a client's chart. The client is alert and oriented. No bowel movement has been documented for 5 days. What is the first action of the nurse?

Verify the information with the client.

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client?

Weight gain of 3 pounds (1.5 kilograms) over 1-2 days

After completing the diagnostic reasoning process, the nurse documents a wellness diagnosis. Which of the following would the nurse have most likely identified?

Strengths

A nurse assesses an older adult client with confusion. When collecting clinical information from the client, which factor is the most important for the nurse to consider?

The quality of the data may be low.

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

Validate the client's identified problems.

The nurse is working with a 14-year-old girl who has told the nurse that she would like to try getting to bed a little sooner to get a full night's sleep and have more energy at school. The nurse diagnoses her with the following: Readiness for enhanced sleep related to client's expressed desire to go to bed earlier. Which type of nursing diagnosis is this?

Wellness

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information?

Wellness diagnosis

The nurse is caring for a group of clients in the community. Which of the following clients can the nurse treat independently?

a 15-year-old soccer player with a sprained ankle

The nurse has completed an assessment on a new client. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to

discuss the plan with the client

The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.

seeing things as only right or wrong

A nursing student demonstrates understanding of the different types of nursing diagnoses when choosing which of the following to be an actual diagnosis?

impaired skin integrity

A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?

implementation

A nurse is working with a client who has a history of chronic obstructive pulmonary disease (COPD). While bathing the client, the nurse senses that something is not quite right and takes the client's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following?

intuition

A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to

quickly make a diagnosis without hypothesizing several diagnoses.

The nursing student demonstrates understanding of the different types of client problems when he identifies which of the following to be a collaborative problem?

risk for complication: pneumothorax

A client with a history of chronic renal failure is receiving continuous intravenous fluids. The nurse understands that this client is at risk for fluid overload. How should the nurse document this potential client concern?

risk for fluid overload risk associated with the client's history of chronic renal failure and currently receiving continuous intravenous fluids

The nurse collects data from a client with a nonproductive cough and labored respirations at a rate of 24/minute. What other data should the nurse collect before formulating an appropriate nursing diagnosis?

status of breath sounds

One characteristic of a nurse who is a critical thinker is the ability to

validate information and judgments.

A nurse understands that the identified strengths found during the assessment of a client are used for which of the following nursing diagnoses?

wellness diagnosis

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the client has the opportunity for an enhanced health state:

wellness diagnosis