Chapters 15-20*

A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of the following represents the best response? 1. "A person with the educational background to solve problems." 2. "A person who finds the problem and does what is best to fix it." 3. "It's someone who uses the scientific method to solve problems." 4. "Someone who uses a system to work through and solve a problem."

"A person who finds the problem and does what is best to fix it."

A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client. Which of the following responses by the clinical instructor is most instructional? 1. "After defining the client's symptomatology, eliminate those nursing diagnoses that are not supported by the database." 2. "Assess your client and then select the nursing diagnosis that has the greatest number of observable defining characteristics." 3. "After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable." 4. "With experience you will become skilled at identifying the defining characteristics of a nursing diagnosis in your client. Until that time use a nursing diagnosis book to help in the selection process."

"After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable."

A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client. Which of the following responses by the clinical instructor is most instructional? A. "After defining the client's symptomatology, eliminate those nursing diagnoses that are not supported by the database." B. "Assess your client and then select the nursing diagnosis that has the greatest number of observable defining characteristics." C. "After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable." D. "With experience you will become skilled at identifying the defining characteristics of a nursing diagnosis in your client. Until that time use a nursing diagnosis book to help in the selection process."

"After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable."

Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor? A. "I can tell when my Hispanic clients are in pain." B. "Moaning is a classic sign of pain in most cultures." C. "All clients will tell you when they need pain medication." D. "Chronic pain is difficult to manage especially for the stoic individual."

"All clients will tell you when they need pain medication."

Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor? 1. "I can tell when my Hispanic clients are in pain." 2. "Moaning is a classic sign of pain in most cultures." 3. "All clients will tell you when they need pain medication." 4. "Chronic pain is difficult to manage especially for the stoic individual."

"All clients will tell you when they need pain medication."

Which of the following statements made by a new graduate nurse regarding a client's care needs requires follow-up by the mentor? 1. "No one really enjoys being hospitalized." 2. "Every client is offered a back rub at bedtime." 3. "All post-surgery clients are reluctant to ambulate." 4. "I always spend extra time with new clients to help them relax."

"All post-surgery clients are reluctant to ambulate."

Which of the following questions will provide the nurse with the best understanding of a terminally ill client's spiritual needs? A. "Do you have a religious preference?" B. "Have you given thought to your spiritual needs?" C. "Is there a particular clergy you would like to visit with?" D. "Are there any spiritual needs you have that I may help with?"

"Are there any spiritual needs you have that I may help with?"

The nurse is performing a problem-focused assessment when the client reports pain in his left shoulder. Which of the following nursing questions has priority when determining the nature of the pain? A. "What makes the pain worse?" B. "When did you first notice the pain?" C. "What do you do to lessen the pain?" D. "Can you rate your pain using the pain scale that we've discussed?"

"Can you rate your pain using the pain scale that we've discussed?"

The client is able to ambulate without signs or symptoms of shortness of breath. Which statement by the nurse is the best example of an objective evaluation of the client's goal attainment? a. "Client has no pain after ambulating." b. "Client has no manifestations of nausea while up in hall." c. "Client walked well and did not have any problem when up." d. "Client has no evidence of respiratory distress when ambulating."

"Client has no evidence of respiratory distress when ambulating."

Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept map to client care? A. "Concept maps help me see the whole client, not just individual health problems." B. "Concept maps can be easily edited to reflect a client's ever changing health needs." C. "I need help organizing my assessment data and concept mapping is really good for that." D. "I like concept mapping because it helps me focus on how the disease processes affect the client."

"Concept maps help me see the whole client, not just individual health problems."

The nurse is conducting an interview with the client and wants to clarify information that the client has shared. Which response by the nurse is an example of the clarifying technique of communication? A. "I understand how you must feel." B. "This medication is used to lower your blood pressure." C. "You appear anxious. You're wringing your hands constantly." D. "Could you give me an example of how you handle stressors?"

"Could you give me an example of how you handle stressors?"

When asked to define the purpose of diagnostic reasoning, the best nursing response is: A. "Diagnostic reasoning is the foundation of the second step of the nursing process; Nursing Diagnosis." B. "The diagnostic reasoning process flows from the assessment process and includes decision-making steps." C. "Diagnostic reasoning includes data clustering, identifying client needs and formulating the diagnosis or problem." D. "Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis."

"Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis."

When asked to define the purpose of diagnostic reasoning, the best nursing response is: 1. "Diagnostic reasoning is the foundation of the second step of the nursing process; Nursing Diagnosis." 2. "The diagnostic reasoning process flows from the assessment process and includes decision-making steps." 3. "Diagnostic reasoning includes data clustering, identifying client needs and formulating the diagnosis or problem." 4. "Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis."

"Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis."

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?"

"Do you feel like you need to use the bathroom?"

The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD). Which of the following questions shows the best example of relevant questioning by the nurse? A. "How long have you been dealing with GERD?" B. "Are you currently taking any medications for your GERD?" C. "Do you follow a particular diet to help manage your GERD?" D. "Do you have any other gastrointestinal problems besides GERD?"

"Do you have any other gastrointestinal problems besides GERD?"

A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care? 1. "I'm sure that friction and pressure have caused this problem." 2. "Please be sure that her ankles are well padded when you place her in bed." 3. "Do you have any suggestions on how we can minimize the pressure to her ankles?" 4. "It was an ineffective turning schedule that allowed this to happen so now we will reposition every hour."

"Do you have any suggestions on how we can minimize the pressure to her ankles?"

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?"

"How many bowel movements a day have you had?"

Which of the following statements made by a nurse regarding personal reflection related to client care requires follow-up by the unit's nurse manager? 1. "Mary and I were comparing foot wound dressing techniques." 2. "I've been caring for orthopedic clients for 10 years and I think I've seen it all." 3. "I can't believe that my client isn't improving after 2 weeks of physical therapy." 4. "I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4."

"I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4."

Which of the following statements made by a nurse practitioner best reflects an understanding of the availability of clinical practice guidelines? a. "Clinical guidelines are so very helpful in providing the most up-to-date nursing care." b. "I'm sure we could get a team together and develop a pressure ulcer prevention protocol or search sites for established protocols." c. "I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site." d. "I'm told that for gerontological issues, the Gerontological Nursing Interventions Research Center (GNIRC) is the primary resource site."

"I am particularly impressed by the type 2 diabetic guidelines posted on the National Guidelines Clearinghouse (NGC) site."

Which of the following statements regarding utilization of personnel made by a new graduate nurse requires immediate follow-up by the nurse's mentor? a. "My LPN is really good with dressings, so I usually delegate them to her." b. "I always take the time to ambulate a post op client the first time out of bed." c. "I always try to help my nursing assistant with the clients who require a total bed bath." d. "I have my nursing assistant take and document all vital signs and intake and outputs."

"I have my nursing assistant take and document all vital signs and intake and outputs."

Which of the following statements best reflects the nurse's correct understanding of the importance of selecting the optimum time for interviewing a client newly admitted to the unit? A. "I'm going to do the client's history before his family leaves so they can help with the admission history questions." B. "You are scheduled for some x-rays, so I'd like to complete this admission history interview before you have to leave." C. "I have some questions to ask you regarding your admission history. I'll be back once you are settled in and comfortable." D. "Please let me know when the blood lab is finished with the new client so I can complete his admission history interview."

"I have some questions to ask you regarding your admission history. I'll be back once you are settled in and comfortable."

Which of the following statements made by a nursing student concerning the use of critical thinking and client care requires follow-up by the nursing instructor? 1. "I feel it's good practice to always have alternative interventions in mind." 2. "I trust my feelings about a client's needs since I work hard at knowing my client." 3. "I always try to keep an open mind about what interventions my client will require." 4. "I will wait until my assessment is completed before determining the client's needs."

"I trust my feelings about a client's needs since I work hard at knowing my client."

Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences. A. "Altered speech" B. "As evidenced by" C. "Recent neurological disturbances" D. "Inability to speak in complete sentences"

"Inability to speak in complete sentences"

Identify the defining characteristics in the following nursing diagnosis: Altered speech related to recent neurological disturbance, as evidenced by inability to speak in complete sentences. 1. "Altered speech" 2. "As evidenced by" 3. "Recent neurological disturbances" 4. "Inability to speak in complete sentences"

"Inability to speak in complete sentences"

When asked to define "Nursing Diagnosis" the nurse's best response is: 1. "It is the second step in the Nursing Process." 2. "It is the process of defining a client's problems." 3. "It correlates a client's problem with a condition a nurse is competent to treat." 4. "It focuses care a licensed nurse can provide with the identified needs of a client."

"It correlates a client's problem with a condition a nurse is competent to treat."

When asked to define "Nursing Diagnosis" the nurse's best response is: A. "It is the second step in the Nursing Process." B. "It is the process of defining a client's problems." C. "It correlates a client's problem with a condition a nurse is competent to treat." D. "It focuses care a licensed nurse can provide with the identified needs of a client."

"It correlates a client's problem with a condition a nurse is competent to treat."

Which of the following questions, asked by a nurse, best reflects an understanding of effective evaluation? a. "Do you feel confident in the use of your glucometer?" b. "Have you been following your low carbohydrate diet?" c. "Any questions regarding the tests you are scheduled for today?" d. "May we review what we discussed earlier about your medications?"

"May we review what we discussed earlier about your medications?"

Which of the following statements made by a client's family is the most reliable for use in the evaluation of a client's outcome? a. "Mom has been eating 90% of all of her meals since she's been home." b. "My daughter is in much less pain now that she is going to physical therapy." c. "My husband has been less depressed since he's been on that antidepressant pill." d. "Mom has been so much better since she's been able to get up and walk by herself."

"Mom has been eating 90% of all of her meals since she's been home."

Which of the following statements made by a new nursing graduate requires immediate follow-up by the nurse's mentor? a. "Older clients with arthritis require additional time to complete to complete their own AM care." b "My client's wife says he loves chocolate milk so I will order his dietary supplement in chocolate." c. "My client just received some bad news regarding her tests. I'll see if the chaplain can visit this evening." d. "Teenage diabetics seem to have a more difficult time making good food choices in order to control their blood sugars."

"My client just received some bad news regarding her tests. I'll see if the chaplain can visit this evening."

Which of the following assessment data provided by a client's family will have the greatest impact on the client's care while hospitalized? A. "Mom falls asleep fastest with the television on." B. "Dad starts off the day with hot coffee; it regulates his bowels." C. "My wife's sister died 4 months ago, and she is still grieving over her loss." D. "My husband doesn't like to let people know his arthritis is bothering him."

"My husband doesn't like to let people know his arthritis is bothering him."

A NAP who works on the unit is also a nursing student. She asks the nurse if she can flush an IV site after the antibiotic infuses. The NAP wants to know as much or even more then her fellow students and would hope for more opportunities like this. Which statement by the nurse is correct to the nursing student who is working as a NAP to complete this delegated task? A. "Sure you can, as long as you have been taught how to flush an IV site." B. "No, not as a NAP." C." Yes, as long as the tubing is identified as the antibiotic tubing to be flushed." D. "Yes, as long as I am with you."

"No, not as a NAP."

Which of the following nursing notes demonstrates the best evaluation of nursing interventions regarding the care provided? a. "Pressure ulcer located on left heel has shown improvement." b. "Pressure ulcer located on left heel has responded to treatment." c. "Pressure ulcer on left heel is no longer producing purulent drainage." d. "Pressure ulcer on left heel has not enlarged in size within the last 24 hours."

"Pressure ulcer on left heel is no longer producing purulent drainage."

A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this client's care needs? 1. "That surgery is painful. I'll get her pain medication ready." 2. "She was sleeping when I checked 15 minutes ago. I'll go back in right now." 3. "I'll be responsible for her PM care so I can spend some uninterrupted time with her." 4. "A mastectomy is a blow to a woman's self image. I'll notify her provider that she is depressed."

"She was sleeping when I checked 15 minutes ago. I'll go back in right now."

Which of the following statements best reflects the nurse's understanding of the function of client reassessment? a. "The client's blood pressure is lower this morning than it was yesterday morning." b. "30 minutes after receiving his pain medication, the client evaluated his pain at 3 out of 10." c. "Turning the client every 2 hours has helped in the healing of the pressure ulcer on his coccyx." d. "Since the client has been ambulating to the bedroom without difficulty, I'll walk with him to the dayroom after dinner."

"Since the client has been ambulating to the bedroom without difficulty, I'll walk with him to the dayroom after dinner."

After visiting with the client, the nurse documents the assessment data. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as subjective data? A. "Client appears sleepy" B. "No physical distress noted" C. "Abdomen soft and non-tender" D. "States feels anxious and tense"

"States feels anxious and tense"

Which of the following is an example of a nurse's statement that reflects using the scientific method in the nursing process? 1. "I believe that this client is getting depressed." 2. "The client doesn't look right to me; I think something is wrong." 3. "The client's husband told me that she is feeling very uncomfortable." 4. "The client reports more pain than yesterday and her blood pressure is elevated."

"The client reports more pain than yesterday, and her blood pressure is elevated."

Which of the following statements made by a new graduate nurse regarding the modification of a client's care plan requires immediate follow-up by the nurse's preceptor? a. "I will review the care plan before I do my charting." b. "The client prefers to bathe at night, so that's what I'll do." c. "I gave her a bed bath this morning, but she could really manage showering herself." d. "The order reads clear liquids, but I hear good bowel sounds and she's really hungry."

"The order reads clear liquids, but I hear good bowel sounds and she's really hungry."

Which of the following best reflects the philosophy of critical thinking as taught by a nurse educator to a nursing student? 1. "Think about several interventions that you could use with this client." 2. "Don't draw subjective inferences about your client—be more objective." 3. "Please think harder—there is a single solution for which I am looking." 4. "Trust your feelings—don't be concerned about trying to find a rationale to support your decision."

"Think about several interventions that you could use with this client."

Which of the following responses best reflects an understanding of the purpose of the "related to" phrase attached to the diagnostic label deficient knowledge regarding postoperative routines? A. "To focus on the cause of the client's needs" B. "To identify the etiology of the client's diagnosis" C. "To provide for individualization of the nursing interventions" D. "To communicate the client's deficits to the nursing staff"

"To provide for individualization of the nursing interventions"

Which of the following responses best reflects an understanding of the purpose of the "related to" phrase attached to the diagnostic label deficient knowledge regarding postoperative routines? 1. "To focus on the cause of the client's needs" 2. "To identify the etiology of the client's diagnosis" 3. "To provide for individualization of the nursing interventions" 4. "To communicate the client's deficits to the nursing staff"

"To provide for individualization of the nursing interventions"

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."

"Validation involves comparing data with other sources for accuracy."

Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the client's depression? A. "Have you ever felt this depressed before?" B. "What do you believe is the cause of your depression?" C. "What makes you feel that you are experiencing depression?" D. "What can we do to make you comfortable while you are here?"

"What do you believe is the cause of your depression?"

The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning? A. "Is your pain worse or better than it was an hour ago?" B. "Do you believe that your nausea is from the new antibiotic?" C. "What do you think has been causing your current depression?" D. "What have you done to alleviate the side effects from your medications?"

"What do you think has been causing your current depression?"

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?"

"What reasons do you think are contributing to your fatigue?"

An ER nurse is interviewing a client who complains of abdominal pain. Which of the following questions asked by the nurse has priority at this time? A. "Can you describe your pain?" B. "Have you had this problem before?" C. "What have you done to ease the pain?" D. "When did your abdominal pain begin?"

"When did your abdominal pain begin?"

You ask another nurse how to collect a laboratory specimen. The nurse raises her eyebrows and asks, "Why don't you figure it out?" What would be the best response? A) Say nothing and walk away. Find a different nurse to help you. B) "When you brush me off like that, it takes me even longer to do my job." C) "Why do you always put me down like that?" D) "I guess I just enjoy having you make fun of me."

"When you brush me off like that, it takes me even longer to do my job."

You ask another nurse how to collect a laboratory specimen. The nurse raises her eyebrows and asks, "Why don't you figure it out?" What would be the best response? A. Say nothing and walk away. Find a different nurse to help you. B. "When you brush me off like that, it takes me even longer to do my job." C. "Why do you always put me down like that?" D. "I guess I just enjoy having you make fun of me."

"When you brush me off like that, it takes me even longer to do my job."

Which of the following statements would be most likely to block communication? A) "You look kind of tired today." B) "Why do you always put so much salt on your food?" C) "It sounds like this has been a hard time for you." D) "If you use your oxygen when you walk, you may be able to walk farther."

"Why do you always put so much salt on your food?"

Which of the following statements would be most likely to block communication? A. "You look kind of tired today." B. "Why do you always put so much salt on your food?" C. "It sounds like this has been a hard time for you." D. "If you use your oxygen when you walk, you may be able to walk farther."

"Why do you always put so much salt on your food?"

A new graduate nurse missed cues regarding the client's emotional state at the time of admission. The most therapeutic response to the nurse by her mentor is: A. "That is why we perform assessments at least daily; so we can catch missed cues." B. "Everyone has missed cues; don't be too hard on yourself and just keep trying." C. "You will be less likely to miss client cues as you acquire more experience with assessments." D. "The positive side to making this mistake is that you won't miss those cues again in another client."

"You will be less likely to miss client cues as you acquire more experience with assessments."

The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case the finding of nausea is which of the following? 1 An objective finding 2 A clinical inference 3 A validation 4 A concomitant symptom

- A concomitant symptom

A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply.) 1 A problem-focused approach 2 A structured comprehensive approach 3 Using multiple visits to gather a complete database 4 Focusing on the functional health pattern of role-relationship

- A problem-focused approach - Using multiple visits to gather a complete database

What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply.) 1 Active listening 2 Back channeling 3 Validating 4 Use of open-ended questions 5 Use of closed-ended questions

- Active listening - Back channeling - Use of open-ended questions

Identify behaviors that foster the development of trust. (Select all that apply.) A. Answer the call light promptly. B. Call the patient by first name unless requested otherwise. C. Do all the care as quickly as possible and leave the room so the patient can rest. D. Answer questions honestly. E. Demonstrate competence when doing treatments.

- Answer the call light promptly. - Answer questions honestly. - Demonstrate competence when doing treatments.

The nurse checks the intravenous (IV) solution that is infusing into the patient's left arm. The IV solution of 9% NS is infusing at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room, the nurse inspects the condition of the dressing and notes the date on the dressing label. In what ways did the nurse evaluate the IV intervention? (Select all that apply.) 1. Checked the IV infusion location in left arm 2. Checked the type of IV solution 3. Confirmed from nurses' notes the time of dressing change and checked label 4. Inspected the condition of the IV dressing

- Confirmed from nurses' notes the time of dressing change and checked label - Inspected the condition of the IV dressing

A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply.) 1 Maintain a neutral facial expression 2 Lean forward when interacting with the patient 3 Acknowledge the patient's answers through head nodding 4 Limit direct eye contact

- Lean forward when interacting with the patient - Acknowledge the patient's answers through head nodding

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

- Patient describing excitement about discharge - Patient's expression of fear regarding upcoming surgery

During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply.) 1 Family report 2 Chest x-ray film 3 Physical examination with auscultation of the lungs 4 Medical record summary of x-ray film findings

- Physical examination with auscultation of the lungs - Medical record summary of x-ray film findings

Your patient has just been told that she has cancer, and she is crying. Which actions facilitate therapeutic communication? (Select all that apply.) A. Turning on the television to her favorite show B. Pulling the curtain to provide privacy C. Offering to discuss information about her condition D. Asking her why she is crying E. Sitting quietly by her bed and hold her hand

- Pulling the curtain to provide privacy - Offering to discuss information about her condition - Sitting quietly by her bed and hold her hand

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order. (Select all that apply) 1 "You say you've lost weight. Tell me how much weight you have lost in the last month." 2 "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3 "I have no further questions. Thank you for your patience." 4 "Tell me what brought you to the hospital." 5 "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor—correct?"

- The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record. - The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement.

8. The nurse follows a series of steps to objectively evaluate the degree of success in achieving outcomes of care. *Place the steps in the correct order.* 1. The nurse judges the extent to which the condition of the skin matches the outcome criteria. 2. The nurse tries to determine why the outcome criteria and actual condition of skin do not agree. 3. The nurse inspects the condition of the skin. 4. The nurse reviews the outcome criteria to identify the desired skin condition. 5. The nurse compares the degree of agreement between desired and actual condition of the skin.

- The nurse reviews the outcome criteria to identify the desired skin condition. - The nurse inspects the condition of the skin. - The nurse compares the degree of agreement between desired and actual condition of the skin. - The nurse judges the extent to which the condition of the skin matches the outcome criteria. - The nurse tries to determine why the outcome

Which of the following statements are key descriptors of the nursing process? (Select All That Apply) a. The nursing process is systematic in that each nursing activity is part of an ordered sequence of activities, depends on the accuracy of the activity that preceded it, & influences the actions that follow it. b. The nursing process is dynamic, meaning that each step flows into the next step & there is a great deal of interaction & overlapping among the five steps. c. The nursing process is interpersonal because the human being is always at the heart of nursing. d. The nursing process is interpersonal in that a patient is viewed as a "problem to be solved" & nurses interact mechanically to provide the solution. e. The nursing process is outcome oriented in that it is a means to an end, which may not always focus on the outcomes that are patient priorities. f. The nursing process is universally applicable in nursing situations, meaning that healthcare is provided in an unchanging environment & the nursing process can be used as a tool in any nursing situation.

- The nursing process is systematic in that each nursing activity is part of an ordered sequence of activities, depends on the accuracy of the activity that preceded it, & influences the actions that follow it. -The nursing process is dynamic, meaning that each step flows into the next step & there is a great deal of interaction & overlapping among the five steps. -The nursing process is interpersonal because the human being is always at the heart of nursing.

A patient comes to a medical clinic with the diagnosis of asthma. The nurse practitioner decides that the patient's obesity adds to the difficulty of breathing; the patient is 5 feet 7 inches tall and weighs 200 pounds (90.7 kg). Based on the nursing diagnosis of imbalanced nutrition: more than body requirements, the practitioner plans to place the patient on a therapeutic diet. Which of the following are evaluative measures for determining if the patient achieves the goal of a desired weight loss? (Select all that apply.) 1. The patient eats 2000 calories a day. 2. The patient is weighed during each clinic visit. 3. The patient discusses factors that increase the risk of an asthma attack. 4. The patient's food diary that tracks intake of daily meals is reviewed.

- The patient is weighed during each clinic visit. - The patient's food diary that tracks intake of daily meals is reviewed.

A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply.) 1 The skin around the wound is tender to touch. 2 Fluid intake for 8 hours is 800 mL. 3 Patient has a heart rate of 78 and regular. 4 Patient has drainage from surgical wound. 5 Body temperature is 101° F (38.3° C). 6 Patient asks, "I'm worried that I won't return to work when I planned."

- The skin around the wound is tender to touch. - Patient has drainage from surgical wound. - Body temperature is 101° F (38.3° C).

Criterion-based standards for evaluation are the

- physiological, emotional, behavioral responses that are a patient's goal and expected outcomes.

The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply.) A) Vital sign results B) Abdominal distention C) Age of patient D) Change in bowel elimination pattern E) Abdominal pain F) No past history of hospitalization

-Abdominal distention -Change in bowel elimination pattern - Abdominal pain

Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply.) A) Acute pain related to lumbar disk repair B) Sleep deprivation related to difficulty falling asleep C) Constipation related to inadequate intake of liquids D) Potential nausea related to nasogastric tube insertion

-Acute pain related to lumbar disk repair -Sleep deprivation related to difficulty falling asleep -Potential nausea related to nasogastric tube insertion

Identify behaviors that foster the development of trust. (Select all that apply.) A) Answer the call light promptly. B) Call the patient by first name unless requested otherwise. C) Do all the care as quickly as possible and leave the room so the patient can rest. D) Answer questions honestly. E) Demonstrate competence when doing treatments.

-Answer the call light promptly -Answer questions honestly. -Demonstrate competence when doing treatments.

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) A) Anxiety related to fear of dying B) Fatigue related to chronic emphysema C) Need for mouth care related to inflamed mucosa D) Risk for infection

-Anxiety related to fear of dying -Risk for infection

What parts of the nursing process cannot be delegated? (Select all that apply) A. Assessments B. Nursing diagnosis C. Plan/outcome D. Interventions E. Evaluations

-Assessments -Nursing diagnosis -Plan/outcome -Evaluations

Which of the following are considered characteristics of a critical thinker? (Select All That Apply) a. Thinking based on the opinions of others b. Being open to all points of view c. Acting like a "know-it-all" d. Resisting "easy answers" to patient problems e. Thinking "outside the box" f. Accepting the status quo

-Being open to all points of view -Resisting "easy answers" to patient problems -Thinking "outside the box"

Which of the following are examples of ethical/legal skills? (Select All That Apply) a. Working collaboratively with the healthcare team as a respected & credible colleague to reach valued goals b. Being trusted to act in ways that advance the interests of patients c. Using technical equipment with sufficient competence & ease to achieve goals with minimal distress to patients d. Selecting nursing interventions that are most likely to yield the desired outcomes e. Being accountable for practice to oneself, the patient, the care-giving team, & society f. Acting as an effective patient advocate

-Being trusted to act in ways that advance the interests of patients -Being accountable for practice to oneself, the patient, the care-giving team, & society -Acting as an effective patient advocate

What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply.) 1 Active listening 2 Open-ended questioning 3 Closed-ended questioning 4 Problem-oriented questioning

-Closed-ended questioning -Problem-oriented questioning

Which of the following is a recognized focus area for quality improvement (performance improvement) evaluations? (Select all that apply.) a. Effective care b. Delivery of care c. Client satisfaction d. Exceeding the standard of care e. Identification of 'missed' client needs f. Multidisciplinary approach to client care

-Effective care -Delivery of care -Client satisfaction -Exceeding the standard of care

Which of the following statements correctly describe the evaluation process? (Select all that apply.) 1. Evaluation is an ongoing process. 2. Evaluation usually reveals obvious changes in patients. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills.

-Evaluation is an ongoing process. -Evaluation involves making clinical decisions. -Evaluation requires the use of assessment skills.

Research has shown that which of the following nursing skills is best strengthened through the use of concept mapping? (Select all that apply.)

-Evaluation of client outcomes in regard to nursing care -Identification of patterns in the client's health assessment data -Recognition of relationships among the client's various health issues -Planning specialized nursing interventions to meet a clients health need

1. Research has shown that which of the following nursing skills is best strengthened through the use of concept mapping? (Select all that apply.) A. Client teaching related to health and wellness topics B. Evaluation of client outcomes in regards to nursing care C. Identification of patterns in the client's health assessment data D. Recognition of relationships among the client's various health issues E. Planning specialized nursing interventions to meet a client's health needs F. Facilitating assessment data collection through observation and communication

-Evaluation of client outcomes in regards to nursing care -Identification of patterns in the client's health assessment data -Recognition of relationships among the client's various health issues -Planning specialized nursing interventions to meet a client's health needs

During the planning phase of the nursing process, the nurse along with the client decides which of the following? (Select all that apply.) A) Interventions B) Nursing diagnosis C) Expected outcomes D) Client-centered goals E) Nurse-centered priorities

-Expected outcomes -Client-centered goals

Which of the following are examples of collaborative problems? (Select all that apply.) A) Nausea B) Hemorrhage C) Wound infection D) Fear

-Hemorrhage -Wound infection

The nurse has determined that the assessment data have resulted in a strong inference that the client is suffering from depression. Which of the following client responses to nursing questions best supports the possibility of depression? (Select all that apply.)

-I just can't seem to get excited about anything anymore. -The family always thought that my father was depressed.

The goal of the orientation phase of a nursing interview is to: (select all that apply)

-Initiate the nurse-client relationship -Begin identifying the client's needs -Earn the trust and confidence of the client

A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? 1 So you've had an upset stomach and began vomiting—correct? 2 Have you taken anything for your stomach? 3 Is anything else bothering you? 4 Have you taken any medication for your vomiting?

-Is anything else bothering you?

The scope of a client's health problem is a result of which of the following factors? (Select all that apply.) 1. Religious beliefs 2. Life experiences 3. Lifestyle choices 4. Work environment 5. Family relationships 6. Educational background

-Life experiences -Lifestyle choices -Work environment -Family relationships

The scope of a client's health problem is a result of which of the following factors? (Select all that apply.)

-Life experiences -Lifestyle choices -Work environment -Family relationships

Which of the following are defining characteristics for the nursing diagnosis of Impaired urinary elimination? (Select all that apply.) A) Nocturia B) Frequency C) Urinary retention D) Inadequate urinary output E) Receipt of intravenous fluids F) Sensation of bladder fullness"

-Nocturia -Frequency -Urinary retention

The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply.) A) Daughter's concern of mother's risk for injury B) Pacing C) Patient getting lost easily D) Daughter working part time E) Getting up frequently

-Pacing -Patient getting lost easily -Getting up frequently

Your patient has just been told that she has cancer, and she is crying. Which actions facilitate therapeutic communication? (Select all that apply.) A) Turning on the television to her favorite show B) Pulling the curtain to provide privacy C) Offering to discuss information about her condition D) Asking her why she is crying E) Sitting quietly by her bed and hold her hand

-Pulling the curtain to provide privacy -Offering to discuss information about her condition -Sitting quietly by her bed and hold her hand

Unmet and partially met goals require the nurse to do which of the following? (Select all that apply.) 1. Redefine priorities 2. Continue intervention 3. Discontinue care plan 4. Gather assessment data on a different nursing diagnosis 5. Compare the patient's response with that of another patient

-Redefine priorities -Continue intervention

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an UAP. Which of the following information should the nurse share with the UAP? (Select all that apply.) A. The client is in room 203 - Bed B. B. The roommate is up independently. C. The client ambulates with his slippers on over his antiembolic stockings. D. The client uses a front-wheeled walker when ambulating. E. The client had pain medication 30 min ago. F. The client is allergic to codeine. G. The client should ambulate at least 50 ft. H. The client ate 50% of his breakfast this morning.

-The client is in room 203 - Bed B. -The client ambulates with his slippers on over his antiembolic stockings. -The client uses a front-wheeled walker when ambulating. -The client had pain medication 30 min ago. -The client should ambulate at least 50 ft.

In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.) A) The nurse who listens to lung sounds after a patient reports "difficulty breathing" B) The nurse who considers conflicting cues in deciding which diagnostic label to choose C) The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema D) The nurse who identifies a diagnosis on the basis of a single defining characteristic

-The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema -The nurse who identifies a diagnosis on the basis of a single defining characteristic

Which of the following accurately describe the role of documenting in the nursing process? (Select All That Apply) a. The patient record is the chief means of communication among members of the interdisciplinary team. b. If a nurse is accused of negligent care, a nurse's word that he/she faithfully assessed the patient's needs, diagnosed problems, & implemented & evaluated an effective plan of care is his/her best defense. c. Legally speaking, a nursing action not documented is a nursing action not performed. d. It is helpful to practice documentation while learning any given nursing activity. e. The content of the patient report & nursing documentation helps to establish nursing priorities in a practice setting. f. Because data collection is ongoing & responsive to changes in the patient's condition, it should be documented in the final step of the nursing process.

-The patient record is the chief means of communication among members of the interdisciplinary team. -Legally speaking, a nursing action not documented is a nursing action not performed. -It is helpful to practice documentation while learning any given nursing activity. -The content of the patient report & nursing documentation helps to establish nursing priorities in a practice setting.

Which of the following statements describe the use of problem solving in the nursing process? (Select All That Apply) a. The trial-and-error problem-solving method is used extensively in the nursing process. b. The trial-and-error problem-solving method is recommended as a guide for nursing practice. c. The scientific problem-solving method is closely related to the more general problem-solving process (the nursing process) commonly used by healthcare professionals as they work with patients. d. Nurse theorists & educators advocate basing clinical judgments on data alone in an attempt to establish nursing as a science, worthy of the respect of other professions. e. Today, nurses acknowledge the positive role of intuitive thinking in clinical decision making. f. Critical thinking in nursing can be intuitive or logical or a combination of both.

-The scientific problem-solving method is closely related to the more general problem-solving process (the nursing process) commonly used by healthcare professionals as they work with patients. -Today, nurses acknowledge the positive role of intuitive thinking in clinical decision making. -Critical thinking in nursing can be intuitive or logical or a combination of both.

Which barrier can an RN experience when delegating? (Select all that apply) A. There is insufficient evidence of education, certification, and validation of the NAP. B. There are policies, procedures, and/or protocols in place for delegation to NAP that vary state to state. C. The delegated tasks are not universal in all agencies and states. D. The new nurse views delegation as the inability of the RN to complete the care. E. The agency's organizational leadership does not support maintaining the education and preparation to delegate.

-There is insufficient evidence of education, certification, and validation of the NAP. -There are policies, procedures, and/or protocols in place for delegation to NAP that vary state to state. -The delegated tasks are not universal in all agencies and states. -The new nurse views delegation as the inability of the RN to complete the care. -The agency's organizational leadership does not support maintaining the education and preparation to delegate.

A nurse from the intensive care unit has been asked to work on a medical-surgical unit. What information will the nurse need in regard to working with NAP on a medical-surgical unit? (Select all that apply) A. Documentation of license B. Training received C. Orientation received D. Competencies documented E. Usual patient loads for NAP's F. Number of previous rotations on the medical-surgical unit.

-Training received -Orientation received -Competencies documented

Which of the following statements made by the nurse should be included in the orientation phase of a nursing interview? (Select all that apply.)

-Your'e answers will be kept confidential. -My name is Susan Smith and I'm a registered nurse. -I need to ask you some questions that will help with planning your care. -Only those directly involved in your care will have access to this information.

What technique(s) best encourage(s) a patient to tell his or her full story?

-active listening -back channeling -open-ended questions

concept map

-allows nurses to obtain a holistic perspective of health care needs -a visual representation that allows nurses to graphically illustrate the connections between a client's health problems

What are the 2 stages of assessment?

1. Collection and verification of data 2. analysis of data

Care plan revision

1. Determine if your goals have been met, and then adjust the plan of care accordingly. 2. determine if the plan of care continues or if revisions are necessary. 3. unmet and partially met goals require you to continue intervention.

Modifying a Care plan

1. Identify the factors that interfere with goal achievement or an error in nursing judgment.

Discontinuing a Care plan

1. If the nurse and the patient agree that the expected outcomes and goals have been met, then discontinue that portion of the care plan. 2. documentation of a discontinued plan ensures that other nurses will not unnecessarily continue intervention.

Steps for modifying a care plan

1. Reassessment 2. Redefining diagnoses 3. Goals and expected outcomes 4. Intervention

Identify the 4 steps of the interview process:

1. Set the stage. this is the orientation stage of the interview 2. gather information about the patients chief concerns or problems and set an agenda (patient's) 3. Collect the assessment (nursing health history). 4. Terminate the interview, Summarize your information and check for accuracy of the information collected

The evaluation of Interventions examines two factors:

1. The appropriateness of the interventions selected and 2. the correct application of the intervention

Evaluative measures

1. are assessment skills and technique (observation, physiological measurement, use of measurement scales, patient interviews). 2. are the same as assessment measures, but you perform them at the point of care when your make decisions about a patients status and progress. 3. is used to determine whether the problem as remained the same, improved, worsened, or otherwise changed.

Reassessment of a care plan

1. is necessary if a nursing diagnosis is unresolved or if you determine that perhaps a new problem has developed. 2. a complete reassessment of a patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan.

The purpose of Nursing outcomes classification (NOC)

1. is to identify, label, validate and classify nurse-sensitive patient outcomes. 2. is to field test and validate the classification. 3. is to define and test measurement procedures for the outcomes and indicators using clinical data.

Goals and Expected outcomes

1. when revising a care plan, review the goal and expected outcomes for necessary changes. 2. Determine if the goals were appropriate, realistic, and time-appropriate

When the nurse takes the patient's nursing history, he or she sits: A) Next to the patient. B) 4 to 12 feet from the patient. C) 18 inches to 4 feet from the patient. D) 12 inches to 3 feet from the patient.

18 inches to 4 feet from the patient.

When the nurse takes the patient's nursing history, he or she sits: A. Next to the patient. B. 4 to 12 feet from the patient. C. 18 inches to 4 feet from the patient. D. 12 inches to 3 feet from the patient.

18 inches to 4 feet from the patient.

A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. _____ 1. Considers context of patient's health problem and selects a related factor _____ 2. Reviews assessment data, noting objective and subjective clinical criteria _____ 3. Clusters clinical criteria that form a pattern _____ 4. Chooses diagnostic label

2, 3, 4, 1

When obtaining subjective assessment data, the nurse recognizes which of the following client scenarios as being the most likely to produce accurate, credible information? A. A 50-year-old in the ED reporting chest pain B. A 70-year-old admitted with fever of unknown origin C. A 81-year-old receiving follow-up treatment for a hip replacement D. A 22-year-old being treated at a clinic for a sexually transmitted disease

A 81-year-old receiving follow-up treatment for a hip replacement

Which of the following clients should be prioritized with the most urgent need for a nursing assessment?

A client who the nursing assistant found crying in the bathroom

Which of the following clients should be prioritized with the most urgent need for a nursing assessment? 1. A new admission admitted for swelling in the right ankle and knee 2. A second day postoperative client who received pain medication 30 minutes ago 3. A client who the nursing assistant found crying in the bathroom 4. A client ready for discharge who requires a final assessment and documentation

A client who the nursing assistant found crying in the bathroom

A nursing diagnosis is: A) The diagnosis and treatment of human responses to health and illness B) The advancement of the development, testing, and refinement of a common nursing language C) A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes D) The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests"

A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes

Reassessment:

A complete reassessment of all patient factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. Reassessment requires critical thinking as you compare new data about the patient's condition with previously assessed information.

Critical Thinking

A continuos process characterized by open-mindedness, continual inquiry, perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant

Define the following components of the diagnostic reasoning process. (Data cluster)

A data cluster is a set of signs and symptoms gathered during assessment that help you group them together in a logical way.

Explain the following components of a nursing diagnosis. (Diagnostic label)

A diagnostic label is the name of the diagnosis as approved by NANDA; it describes the essence of the patient's response to health conditions.

Goals:

A goal is the expected behavior or response that indicates resolution of a nursing diagnosis or maintenance of a healthy state. It is a summary statement of what will be accomplished when the patient has met all expected outcomes

The client smokes two packs of cigarettes per day. The nurse works with the client, and they agree that he will smoke one cigarette less each week until he is down to one pack per day. In 3 weeks, the client is smoking two and a half packs of cigarettes per day. This is an example of: a. A realistic goal b. A compliant client c. A negative evaluation d. A nonmeasurable goal

A negative evaluation

Which of the following is the best example of a nurse's use of reflection? 1. The nurse places a client experiencing respiratory difficulties in a high-Fowler's position. 2. The nurse calls the provider when a client reports feeling "chilled and achy" while having an oral temperature of 100.2° F. 3. While caring for a client with a history of asthma, the nurse assesses the client's pulse oximetry reading when he "doesn't sound right." 4. A nurse tells a client; "When you refused to go to physical therapy earlier today, I believe you were upset about something else besides the appointment time."

A nurse tells a client; "When you refused to go to physical therapy earlier today, I believe you were upset about something else besides the appointment time."

Which of the following is the best example of a nurse's use of reflection?

A nurse tells a client; When you refused to go to physical therapy earlier today, I believe you were upset about something else besides the appointment time.

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.

A patient's feelings, perceptions, and reported symptoms.

A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of the following represents the best response?

A person who finds the problem and does what is best to fix it

Explain the following components of a nursing diagnosis. (Related factor)

A related factor is a condition or etiology identified from the patient's assessment data, or actual or potential responses to the health problem.

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. A scientific knowledge base

A scientific knowledge base

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

A scientific knowledge base

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

Abdominal distention

To solve a problem, the nurse manager understands that the most important problem-solving step is: a. The implementation phase. b. Identification of numerous solutions. c. Accurate identification of the problem. d. Evaluation of the effectiveness of problem resolution.

Accurate identification of the problem.

Dependent nursing interventions

Actions that require an order from a physician or another health care professional.

12. 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

Actively participating in all clinical experiences

When clustering data according to functional health patterns, the nurse determines that the client is only able to ambulate short distances without becoming fatigued and requires rest periods during morning care. The health pattern that requires intervention is identified by the nurse as:

Activity and exercise

When clustering data according to functional health patterns, the nurse determines that the client is only able to ambulate short distances without becoming fatigued and requires rest periods during morning care. The health pattern that requires intervention is identified by the nurse as: A. Respiratory B. Activity and exercise C. Sleep and rest pattern D. Self-care deficit: activities of daily living

Activity and exercise

The nursing diagnosis Hypothermia is an example of which of the following? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D) Wellness nursing diagnosis"

Actual nursing diagnosis

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

Acute pain

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.

Adapting the positioning technique to the situation.

The implementation of nursing care often requires

Additional knowledge, nursing skills, and personnel resources.

What is the most appropriate task for the NAP to perform once delegated by the nurse to assist in patient care? A. Administer a soapsuds enema to a patient who is constipated. B. Notify the family of a patient who has died. C. Reinforce teaching a patient who is a recent above-the-knee- amputee (AKA). D. Press the silence button on the beeping feeding pump until the RN arrives.

Administer a soapsuds enema to a patient who is constipated.

Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated?

Administering a cleansing enema in preparation for radiological testing

A nursing student expresses some confusion about identifying the appropriate nursing diagnosis for a specific client. Which of the following responses by the clinical instructor is most instructional?

After assessing the client, compare their symptoms carefully to the defining characteristic of the nursing diagnosis in order to support or eliminate it as applicable.

Redefining Diagnoses:

After reassessment, determine which nursing diagnoses are accurate for the situation. Ask whether you selected the correct diagnosis and whether the diagnosis and the etiological factor are current. Then revise the problem list to reflect the patient's changed status. Sometimes you make a new diagnosis.

The nurse is going to perform the admission history for a newly admitted client on the medical unit. The optimum time for completion of the history is planned for:

After the client has become comfortably oriented to the room

The nurse is going to perform the admission history for a newly admitted client on the medical unit. The optimum time for completion of the history is planned for: A. Coordination with the physician's visit B. The time when the client's family are visiting C. Immediately before the client's scheduled MRI testing D. After the client has become comfortably oriented to the room

After the client has become comfortably oriented to the room

Discontinuing a Care Plan:

After you determine that expected outcomes and goals have been met, confirm this evaluation with the patient when possible. If you and the patient agree, you discontinue that portion of the care plan. Documentation of a discontinued plan ensures that other nurses will not unnecessarily continue interventions for that portion of the plan of care

Which of the following statements made by a nursing student regarding the cultural characteristics of pain requires immediate follow-up by the clinical instructor?

All clients will tell you when they need pain medication.

Which of the following traits helps nurses develop the attitudes & dispositions to think critically? a. Thinking independently b. Being intellectually humble c. Being curious & persevering d. All of the above

All of the above

Which of the following statements made by a new graduate nurse regarding a client's care needs requires follow-up by the mentor?

All post-surgery clients are reluctant to ambulate.

Curiosity

Always ask why. A clinical sign or symptom often indicates a variety of problems. Explore and learn more about the patient so as to make appropriate clinical judgments.

Which of the following nursing actions is most likely a result of the nurse's clinical experience? a. Placing an immobile client on a turning schedule b Always assessing a client's IV site before hanging a new bag of fluid c. Requesting that the nursing assistant have vital signs recorded by 0815 d. Administering a pain medication 30 minutes before changing a burn dressing

Always assessing a client's IV site before hanging a new bag of fluid

Which of the following groups legitimized the steps of the nursing process in 1973 by developing standards of practice to guide nursing practice? a. American Nurses Association Congress for Nursing Practice b. Joint Commission on Accreditation of Healthcare Organizations c. National League of Nursing d. American Association of Critical Care Nursing

American Nurses Association Congress for Nursing Practice

When obtaining subjective assessment data, the nurse recognizes which of the following client scenarios as being the most likely to produce accurate, credible information?

An 81-year-old receiving follow-up treatment for a hip replacement

Quality Improvement

An approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others

Evaluation involves what two components

An examination of a condition or situation and a judgment as to whether change has occurred.

Expected Outcomes.

An expected outcome is an end result that is measurable, desirable, and observable and translates into observable patient behaviors.

Which of the following statements best defines quality improvement (performance improvement)? a. The assessment of the delivery system responsible for the implementation of client-oriented interventions b. Integration of evidence-based practice research into the delivery process used to implement client-oriented interventions c. High-priority evaluation process directed towards differentiating between good and poor intervention delivery by providers d. An ongoing evaluation of interventions that is used to improve the delivery of health care for the purpose of managing the client's needs

An ongoing evaluation of interventions that is used to improve the delivery of health care for the purpose of managing the client's needs

Analyticity

Analyze potentially problematic situations; anticipate possible results or consequences; value reason; use evidence-based knowledge.

Define the following components of the diagnostic reasoning process. (Data interpretation)

Analyzing clusters of defining characteristics or risk factors.

A client expresses concern over a scheduled intravenous pyelogram by stating, "I don't know what to expect." Which of the following nursing diagnoses is most appropriate for this client need? A. Anxiety related to scheduled diagnostic testing B. Knowledge deficit regarding need for diagnostic testing C. Knowledge deficit related to need for intravenous pyelogram D. Anxiety related to lack of knowledge concerning intravenous pyelogram

Anxiety related to lack of knowledge concerning intravenous pyelogram

A client expresses concern over a scheduled intravenous pyelogram by stating, I don't know what to expect. Which of the following nursing diagnoses is most appropriate for this client need?

Anxiety related to lack of knowledge concerning intravenous pyelogram

Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is the following:

Apply two 4 4 dry gauze dressing pads tid.

Use of the intellectual standard of critical thinking implies that the nurse:

Approaches assessment logically

Use of the intellectual standard of critical thinking implies that the nurse: 1. Questions the physician's order 2. Recognizes conflicts of interest 3. Listens to both sides of the story 4. Approaches assessment logically

Approaches assessment logically

Expected outcome

Are measurable criteria to evaluate goal achievement.

Critical pathways

Are patient care management plans that provide the interdisciplinary health team with the activities and tasks to be put into practice sequentially (over time).

Defining characteristics

Are the critical criteria or assessment findings that support an actual nursing diagnosis.

Which of the following questions will provide the nurse with the best understanding of a terminally ill clients spiritual needs?

Are there any spiritual needs you have that I may help with?

Indirect care interventions

Are treatments performed away from but on behalf of the patient or group of patients.

Direct care interventions

Are treatments performed through interactions with patients

Before beginning to perform interventions, be sure the client is

As physically and psychologically comfortable as possible.

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 of Decisional 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.

Ask a more experienced nurse to listen also.

The nursing care plan calls for the patient, a 300-pound woman, to be turned every 2 hours. The client is unable to assist with turning. The nurse knows. that she may hurt her back if she attempts to turn the client by herself. The nurse should

Ask another nurse to help her turn the client

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.

Ask the nursing assistant to record the patient's vital signs before administering medications.

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 nocorrelation 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.

Ask the patient about his usual sleep patterns and the onset of having difficulty resting.

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.

Ask the patient about the facial grimacing with movement.

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.

Ask the patient to describe the type of reaction.

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.

Ask the patient why she is crying.

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 nonpharmacological, 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

Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past

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.

Asking for an orientation to the unit.

7. A clinic nurse has observed another nurse deviating from agency policy in performing wound care. The best approach for the clinic nurse to take is to: a. Stay out of it. b. Inform the nursing supervisor. c. Fill out a notification form (incident report). d. Assess the risk to the client and the agency before proceeding.

Assess the risk to the client and the agency before proceeding.

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

Assessment

First step of the nursing process. Activities required in the first step are data collection, validation, sorting, and documentation

Assessment

Five steps of Nursing process

Assessment Diagnosis Planning Implementation Evaluation

The maintenance department wishes to have the nursing lounge renovated, so the lounge will be more "user-friendly." The department asks the nursing staff to make a wish list of everything that they would like to see in the new lounge. This process is an example of which part of the decision-making process? a. Assessment/Data collection b. Planning c. Data interpretation d. Generating hypotheses

Assessment/Data collection

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

Assigning diagnoses while completing the database

For a client with a nursing diagnosis of impaired physical mobility related to bilateral arm casts, the nurse should select which of the following methods of nursing intervention? a. Teaching b. Counseling c. Compensating for adverse reactions d. Assisting with activities of daily living (ADLs)

Assisting with activities of daily living (ADLs)

Which type of critical thinking is this: "Concrete and based on a set of rules or principles" A. Basic Critical thinking B. Complex critical thinking C. Commitment

Basic

Inquisitiveness

Be eager to acquire knowledge and learn explanations even when applications of the knowledge are not immediately clear. Value learning for learning's sake.

Analysis

Be open minded as you look at info about patient

Interpretation

Be orderly in data collection. Look for patterns to catorgorize data (nursing diagnosis)

Systematicity

Be organized, focused; work hard in any inquiry.

Discipline

Be thorough in whatever you do. Use known scientific and practice-based criteria for activities such as assessment and evaluation. Take time to be thorough and manage your time effectively. Being disciplined help you identify problems more accurately and select the approp intervention. ex: Prob: pain Nurse asks, scale of 1-10? where? how long? what makes it worse?

Open- Mindedness

Be tolerant of different views. Be sensitive to the possibility of your own prejudices, respect the right of others to have different opinions

Open-mindedness

Be tolerant of different views; be sensitive to the possibility of your own prejudices; respect the right of others to have different opinions.

Risk taking

Be willing to recommend alternative approaches to Nursing Care., Taking a chance without knowing if you'll succeed or fail. Follow safety guidelines, analyze any potential dangers to pt; act in well-reasoned, logical & thoughtful manner.

A client reports to the nurse that the room is "too hot." Which of the following nursing actions best reflects the nurse's understanding of the therapeutic manipulation of the client's environment? a. Bringing a portable fan into the room b. Assisting the client in the removal of excess clothing c. Offering to ambulate the client into the visiting lounge d. Closing the blinds to minimize the sunshine through the windows

Bringing a portable fan into the room

A client's wound is not healing and appears to be worsening with the current treatment. What is the first option the nurse should consider? A) Notifying the physician B) Calling the wound care nurse C) Consulting with another nurse D) Changing the wound care treatment"

Calling the wound care nurse

The nurse is performing a problem-focused assessment when the client reports pain in his left shoulder. Which of the following nursing questions has priority when determining the nature of the pain?

Can you rate your pain using the pain scale that we've discussed?

Interdisciplinary care plans

Care plans that include all contributions from all disciplines involved in patient care.

Nursing interventions may be categorized based upon the degree of nursing autonomy. Which of the following nursing interventions is considered as physician- or prescriber-initiated?

Changing a dressing 2 times each day

Decision making is described by the nursing educator as the process one uses to: a. Solve a problem. b. Choose between alternatives. c. Reflect on a certain situation. d. Generate ideas.

Choose between alternatives.

Of the following statements, which one is an example of an appropriately written nursing diagnosis?

Chronic pain related to insufficient use of medication

Of the following statements, which one is an example of an appropriately written nursing diagnosis? A. Anxiety related to cardiac monitor B. Pain related to difficulty ambulating C. Chronic pain related to insufficient use of medication D. Bedpan required frequently as a result of altered elimination pattern

Chronic pain related to insufficient use of medication

Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Anxiety related to cardiac monitor 2. Pain related to difficulty ambulating 3. Chronic pain related to insufficient use of medication 4. Bedpan required frequently as a result of altered elimination pattern

Chronic pain related to insufficient use of medication

Which subjective assessment data are most supportive of a client's diagnosis of anxiety? A. Diaphoretic and cool skin B. An apical pulse rate of 120 beats per minute C. Reports "needing to leave now" D. Claims "something is terribly wrong"

Claims "something is terribly wrong"

Which subjective assessment data are most supportive of a client's diagnosis of anxiety?

Claims something is terribly wrong

The nurse states, "When you tell me that you're having a hard time living up to expectations, are you talking about your family's expectations?" The nurse is using which therapeutic communication technique? A) Providing information B) Clarifying C) Focusing D) Paraphrasing

Clarifying

The nurse states, "When you tell me that you're having a hard time living up to expectations, are you talking about your family's expectations?" The nurse is using which therapeutic communication technique? A. Providing information B. Clarifying C. Focusing D. Paraphrasing

Clarifying

Source of data that is the best source for information

Client

The primary source of information when completing an assessment of a client that is alert and oriented as he is admitted to the medical center for diagnostic testing is the:

Client

The primary source of information when completing an assessment of a client that is alert and oriented as he is admitted to the medical center for diagnostic testing is the: A. Client B. Physician C. Family member D. Experienced unit nurse

Client

The process of data collection should begin with the nurse performing a:

Client interview

The process of data collection should begin with the nurse performing a: A. Physical exam B. Client interview C. Review of medical records D. Discussion with other health team members

Client interview

Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process?

Client is observed grimacing when walking to bathroom.

Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process? A. Paternal family history of osteoarthritis has been reported. B. Client is observed grimacing when walking to bathroom. C. Right knee appears edematous when compared to left knee. D. Client rated the pain felt after walking at a 6 on a scale of 1 to 10.

Client is observed grimacing when walking to bathroom.

Which of the following assessment findings best supports the nursing diagnosis of pain in right knee joint related to degenerative process? 1. Paternal family history of osteoarthritis has been reported. 2. Client is observed grimacing when walking to bathroom. 3. Right knee appears edematous when compared to left knee. 4. Client rated the pain felt after walking at a 6 on a scale of 1 to 10.

Client is observed grimacing when walking to bathroom.

Which of the following assessment findings best supports the nursing diagnosis of Pain in right knee joint related to degenerative process?

Client observed grimacing when walking to bathroom.

The nurse has identified a nursing diagnosis of knowledge deficit regarding the need to monitor blood glucose levels daily. Which of the following statements best reflects the client's understanding of the need for therapy? a. Client agrees to test blood glucose levels 4 times a day. b. Client records blood glucose levels for a 3-week period. c. Client is observed testing his blood glucose level before breakfast. d. Client is able to demonstrate the proper technique for performing a finger stick.

Client records blood glucose levels for a 3-week period.

Which of the following outcomes best reflects a nurse-sensitive client outcome? a. Client will consume 75% of all meals. b. Client will perform personal hygiene daily. c. Client will experience no falls during hospitalization. d. Client will report lessened anxiety regarding surgical procedure.

Client will experience no falls during hospitalization.

The nurse writes the following goal for a client who is hypertensive: Client will maintain a blood pressure within acceptable limits. Which of the following would be the most appropriate outcome criterion?

Client will have a 7 AM blood pressure reading less than 140/90.

A client is newly diagnosed with diabetes mellitus. The nurse identifies a nursing diagnosis of knowledge deficient related to new diagnosis and treatment needs. The most appropriate outcome statement based upon the established criteria is the following:

Client will independently perform subcutaneous insulin injection by 8/31.

Which of the following statements best reflects a goal based on a clinical standard of practice? a. Client will lose 10 pounds in 90 days. b. Client will walk 30 feet with minimal assistance. c. Client's peripheral intravenous site will be free of redness. d. Client's chronic pain will be managed with oral medication by discharge.

Client's peripheral intravenous site will be free of redness.

What is the sources nurse's receive data?

Client, family, health care team, medical records, nurse experience, literature

Biographical information

Clients age, address, occupation, marital status, source of health care, insurance (demographic info)

In order that they are clear and easily understood by other members of the health care team, the nurse recognizes that client goals or outcomes should be documented according to specific criterion. Of the following, the outcome statement that best meets the established criteria is:

Clients respiratory rate will remain within 20 to 24 breaths per minute by 9/24.

problem solving approach that nurses use to define patient problems and select appropriate treatment

Clinical decision making

During an interview, the nurse needs to obtain specific information about the signs and symptoms of the clients health problem. To obtain these data most efficiently, the nurse should use:

Closed-ended questions

During an interview, the nurse needs to obtain specific information about the signs and symptoms of the client's health problem. To obtain these data most efficiently, the nurse should use: A. Channeling B. Open-ended questions C. Closed-ended questions D. Problem-seeking responses

Closed-ended questions

A nurse seeks to organize the data obtained from the client in a logical manner. The organizational method that identifies relationships between factors and symptoms in the database is known as:

Clustering data

A nurse seeks to organize the data obtained from the client in a logical manner. The organizational method that identifies relationships between factors and symptoms in the database is known as: A. Clustering data B. Validating data C. Peer reviewing D. Problem statement

Clustering data

Mrs. Jones states that she gets anxious when she thinks about giving herself insulin. How do you use your understanding of intrapersonal communication to help with this? A) Provide her the opportunity to practice drawing up insulin B) Coach her to give herself positive messages about her ability to do this C) Bring her written material that clearly describes the steps of insulin administration D) Use therapeutic communication to help her express her feeling about giving herself an injection

Coach her to give herself positive messages about her ability to do this

The nurse recognizes the discharge needs of a client following a hip replacement. This is an example of which type of nursing skill? a. Cognitive b. Interactive c. Psychomotor d. Communication

Cognitive

The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview? 1 Setting the stage 2 Gathering information about the patient's chief concerns 3 Collecting the assessment 4 Termination

Collecting the assessment

A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the client's weight, the nurse also considers the age and height. This is an example of:

Comparing data with normal health patterns

A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the client's weight, the nurse also considers the age and height. This is an example of: A. Defining the client problem B. Recognizing gaps in data assessment C. Comparing data with normal health patterns D. Drawing conclusions about the client's response

Comparing data with normal health patterns

A 53-year-old client is seen at the clinic for a yearly physical examination. In evaluating the client's weight, the nurse also considers the age and height. This is an example of: 1. Defining the client problem 2. Recognizing gaps in data assessment 3. Comparing data with normal health patterns 4. Drawing conclusions about the client's response

Comparing data with normal health patterns

The client is given an injection of an antibiotic. Shortly afterwards the client reports hives and itching. The nurse administers an antihistamine to counteract the effect of the antibiotic. The nurse is using which one of the following intervention methods? a. Preventive measures b. Assisting with ADLs c. Preparing for special procedures d. Compensation for adverse reactions

Compensation for adverse reactions

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.

Completes a comprehensive database.

Which type of critical thinking is this: "Willing to consider different options from routine procedures when complex situations develop" A. Basic Critical thinking B. Complex critical thinking C. Commitment

Complex

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

Concept mapping

Identify the purpose of concept mapping a nursing diagnosis.

Concept mapping a nursing diagnosis is a way to graphically represent the connections among concepts (nursing diagnosis) and ideas that are related to a central subject (patient's problem).

Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept mapping to client care?

Concept maps help me see the whole client, not just individual health problems

Which of the following statements made by the nurse reflects the best understanding of the usefulness of a concept map to client care?

Concept maps help me see the whole client, not just individual health problems.

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.

Conduct a nursing health history.

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.

Consider cultural differences during this assessment.

Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is: A) Need for improved bowel function related to change in diet. B) Patient needs improved bowel function related to alteration in elimination. C) Constipation related to inadequate fluid intake. D) Constipation related to hard infrequent stools.

Constipation related to inadequate fluid intake.

The nurse is involved in requesting a management consultation for personnel-related issues. Which of the following is true regarding the consultation process in which the nurse is involved?

Consultation is often used when the exact problem remains unclear.

The nurse is conducting an interview with the client and wants to clarify information that the client has shared. Which response by the nurse is an example of the clarifying technique of communication?

Could you give me an example of how you handle stressors?

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

Creativity

4. During a fire drill, several psychiatric patients become agitated. The nurse manager quickly assigns a staff member to each patient. This autocratic decision style is most appropriate for: a. Routine problems. b. Crisis situations. c. Managers who prefer a "telling" style. d. Followers who cannot agree on a solution.

Crisis situations.

Expected outcomes

Criteria used to determine the effective-ness of a nursing action

The client is receiving postural drainage from physical therapy and intermittent breathing treatments from respiratory therapy. Which type of care plan would be the ideal method to document interventions for this client?

Critical pathway

The primary factor that distinguishes a professional nurse's care from care provided by ancillary nursing staff is: 1. Critical thinking 2. Years of education 3. Professional licensure 4. Complexity of the task

Critical thinking

The primary factor that distinguishes a professional nurses care from care provided by ancillary nursing staff is:

Critical thinking

With regards to client care, the most likely reason that a veteran nurse tends to be a more skillful critical thinker than a new graduate nurse is because:

Critical thinking improves with experience, longevity, and interest

With regards to client care, the most likely reason that a veteran nurse tends to be a more skillful critical thinker than a new graduate nurse is because: 1. The veteran nurse has a varied history of client care experiences 2. Critical thinking improves with experience, longevity, and interest 3. Today's short hospital stays minimize the opportunity to develop critical thinking skills 4. New graduates often lack the self-confidence to take the risks often required of critical decision making

Critical thinking improves with experience, longevity, and interest

The nurse begins to auscultate the client's lungs. While listening, the nurse notices fresh bloody drainage oozing from the abdominal dressing. The nurse stops auscultating and applies direct pressure to the wound site. This is an example of: a. Performing a nursing assessment b. Reorganizing the nursing diagnoses c. Implementing nursing interventions d. Critically analyzing client assessment data

Critically analyzing client assessment data

Which of the following nursing interventions is the best example of the implementation step of the nursing process? 1. Determining that the client's ankle edema is worse after he ambulates 2. Asking the client to rate his ankle pain after receiving oral pain medication 3. Arranging for the client to receive pain medication 30 minutes before his ordered ambulation 4. Crushing the client's pain medication to facilitate easier swallowing and thus minimize the risk of choking

Crushing the client's pain medication to facilitate easier swallowing and thus minimize the risk of choking

Which of the following nursing interventions is the best example of the implementation step of the nursing process?

Crushing the clients pain medication to facilitate easier swallowing and thus minimize the risk of choking

Subjective Data

Data (symptoms) that Client tells you. ex: feelings, perceptions, symptoms

nursing health history

Data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual history and mental and emotional reactions to illness

A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: A) Data collection. B) Data clustering. C) Data interpretation. D) Making a diagnostic statement.

Data interpretation.

Objective Data

Data that is observed during an assessment ex: observation, measurement (bp, heart rate)

a product of critical thinking that focuses on problem resolution

Decision making

Select the statement that best defines the difference between problem solving and decision making: a. Decision-making skills require critical thinking; problem-solving skills do not. b. Problem-solving skills require critical thinking; decision-making skills do not. c. Decision making is a goal-directed effort; problem solving is focused on solving an immediate problem. d. Problem solving is a goal-directed effort; decision making is focused on solving an immediate problem.

Decision making is a goal-directed effort; problem solving is focused on solving an immediate problem.

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.

Decreased oral intake.

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

Decreased oxygen saturation when ambulating and complaints of shortness of breath when getting out of bed

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

Deficient fluid volume

Of the following statements, which one is an example of an appropriately written nursing diagnosis?

Deficient knowledge related to need for cardiac catheterization

Of the following statements, which one is an example of an appropriately written nursing diagnosis? A. Acute pain related to left mastectomy B. Impaired gas exchange related to altered blood gases C. Deficient knowledge related to need for cardiac catheterization D. Need for high protein diet related to alteration in client nutrition

Deficient knowledge related to need for cardiac catheterization

Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Acute pain related to left mastectomy 2. Impaired gas exchange related to altered blood gases 3. Deficient knowledge related to need for cardiac catheterization 4. Need for high protein diet related to alteration in client nutrition

Deficient knowledge related to need for cardiac catheterization

Define the following components of the diagnostic reasoning process. (Defining characteristics)

Defining characteristics are clinical criteria that are observable and verifiable.

Mr. Sakda emigrated from Thailand. When taking care of him, you note that he looks relaxed and smiles but seldom looks at you directly. How do you respond? A) Use therapeutic communication to assess for increased anxiety B) Sit down and position yourself closer so you are at eye level C) Deflect your eyes downward to show respect D) Continue to maintain eye contact

Deflect your eyes downward to show respect

Mr. Sakda emigrated from Thailand. When taking care of him, you note that he looks relaxed and smiles but seldom looks at you directly. How do you respond? A. Use therapeutic communication to assess for increased anxiety B. Sit down and position yourself closer so you are at eye level C. Deflect your eyes downward to show respect D. Continue to maintain eye contact

Deflect your eyes downward to show respect

Transferring the authority and responsibility to another member of the health care team to complete a task, while retaining the accountability

Delegating

The primary reason for documenting discontinued portions of the care plan when a client goal has been met is to ensure: a. Effective use of both nursing time and resources b. Delivery of both timely and relevant nursing care c. Concrete evidence of successful outcome achievement d. Minimal ineffective communication among the nursing staff

Delivery of both timely and relevant nursing care

Which of the following statements best reflects the nurses understanding of the primary nursing related purpose of a concept map?

Demonstrate the relationship between the client's various health problems

Health promotion nursing diagnosis

Desire to increase well-being and actualize human health potential.

Which of the following interpersonal skills is displayed by a nurse who is attentive & responsive to the healthcare needs of individual patients & ensures the continuity of care when leaving the patient? a. Establishing caring relationships b. Enjoying the rewards of mutual interchange c. Developing accountability d. Developing ethical/legal skills

Developing accountability

Which step of the nursing process is a nurse using when she analyzes patient data to determine her patient's strengths following a CVA? A. Assessing B. Diagnosing C. Planning D. Implementing E. Evaluating

Diagnosing

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

Diagnosis

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

Diagnosis

"Unhappy and worried about health" is not a scientifically based nursing diagnosis, and it can lead to error in: A) Data collection B) Date clustering C) Diagnostic label D) Medical diagnosis"

Diagnostic label

process that enables an observer to assign meaning to and classify phenomena in clinical situations by integrating observations and critical thinking

Diagnostic reasoning

When asked to define the purpose of diagnostic reasoning, the best nursing response is:

Diagnostic reasoning involves using the assessment collected on a specific client to logically arrive at an appropriate nursing diagnosis.

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.

Diagnostic reasoning.

Of the following statements, which one is an example of an appropriately written nursing diagnosis?

Diarrhea related to food intolerance

Of the following statements, which one is an example of an appropriately written nursing diagnosis? A. Diarrhea related to food intolerance B. Alteration in comfort related to pain C. Risk for impaired skin integrity related to poor hygiene habits D. Potential complications related to insufficient vascular access

Diarrhea related to food intolerance

Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Diarrhea related to food intolerance 2. Alteration in comfort related to pain 3. Risk for impaired skin integrity related to poor hygiene habits 4. Potential complications related to insufficient vascular access

Diarrhea related to food intolerance

In completing an assessment on an assigned client, the nurse obtains important information for planning nursing care. Which of the following client needs should take priority?

Difficulty breathing

Implementation is the step of the nursing process in which nurses provides

Direct and indirect nursing care interventions to clients.

The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to do which of the following? A) Implement the specialist's recommendations. B) Discuss and review advised strategies with the CNS. C) Report the recommendations to the primary physician. D) Clarify the suggestions with the client and family members."

Discuss and review advised strategies with the CNS.

The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the client's anxiety regarding the procedure?

Discuss the pre- and post-procedure care that will be provided

The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the client's anxiety regarding the procedure? 1. Assure the client that preoperative sedation will be administered. 2. Discuss the pre- and post-procedure care that will be provided. 3. Provide a detailed explanation of why the procedure is necessary. 4. Guarantee that family will be regularly updated during the procedure.

Discuss the pre- and post-procedure care that will be provided.

The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the client's anxiety regarding the procedure? A. Assure the client that preoperative sedation will be administered. B. Discuss the pre- and post-procedure care that will be provided. C. Provide a detailed explanation of why the procedure is necessary. D. Guarantee that family will be regularly updated during the procedure.

Discuss the pre- and postprocedure care that will be provided.

The charge nurse delegated to the NAP six patient to provide AM care. Several hours later, one of the patients called the nurses station stating that they had not had their bed changed or a bath. The Charge nurse went to the patient's room and verified the patient's complaint. What should the nurse do next in this situation? A. Ask all the patients if they have received their medications. B. Follow the NAP the next day to observe completion of the tasks delegated. C. Discuss with the NAP the recent complaint by the patient. D. Disregard the patient's complaint and provide AM care.

Discuss with the NAP the recent complaint by the patient

There are a variety of levels of critical thinking. An example of critical thinking at the complex level is:

Discussing various alternative pain management techniques

There are a variety of levels of critical thinking. An example of critical thinking at the complex level is: 1. Giving medication at the time ordered 2. Following a procedure for catheterization step-by-step 3. Reviewing all clients' medical records thoroughly 4. Discussing various alternative pain management techniques

Discussing various alternative pain management techniques

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

Disruption of tissue integrity

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.

Distinguish the nurse's role from the physician's role.

Sue, a nurse manager, has a staff nurse that has been absent a great deal for the past three months. A whistleblower gives some information to Sue indicating that the staff nurse will be resigning and returning to school. Because of this, Sue decides to do which of the following? a. Immediately fire the staff nurse. b. Speak to the whistleblower and elicit more information. c. Speak to the staff nurse and ask her to resign. d. Do nothing.

Do nothing.

The nurse is conducting an admissions history interview with a client who has a history of gastroesophageal reflux disease (GERD). Which of the following questions shows the best example of relevant questioning by the nurse?

Do you have any other gastrointestinal problems besides GERD?

A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care?

Do you have any suggestions on how we can minimize the pressure to her ankles?

Which of the following characteristics of the nursing process could be defined as a great deal of overlapping interaction among the 5 steps, with each being fluid & flowing into the next step? a. Interpersonal b. Dynamic c. Systematic d. Universally applicable

Dynamic

Which of the following characteristics of the nursing process describes the interaction & overlapping of steps within the process itself? A. Systematic B. Dynamic C. Interpersonal D. Universally Applicable

Dynamic

Which of the following nursing interventions is written correctly? A) Change dressing once a shift. B) Perform neurovascular checks. C) Elevate head of bed 30 degrees before meals. D) Apply continuous passive motion machine during day."

Elevate head of bed 30 degrees before meals.

When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including which of the following? A) Apply a cold pack to the tibia. B) Elevate the leg 5 inches above the heart. C) Perform range-of-motion movement with right leg every 4 hours. D) Administer aspirin 325 mg every 4 hours as needed."

Elevate the leg 5 inches above the heart.

After visiting with the client, the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as objective data?

Elevated blood pressure

After visiting with the client, the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as objective data? A. Pain in the left leg B. Elevated blood pressure C. Fear of impending surgery D. Discomfort upon breathing

Elevated blood pressure

After the nurses who work on an adolescent psychiatric unit have had a brainstorming session, they are ready to resolve the problem of teenagers who are unmanageable. To maximize group effectiveness in decision making and problem solving, the nurse manager has: a. Prevented conflict. b. Formed highly cohesive groups. c. Used majority rule to arrive at decisions. d. Encouraged equal participation among members.

Encouraged equal participation among members.

The nurse realizes that in order to share information from a client's medical record with another facility, the client must provide written consent. The primary reason for this requirement is to: A. Facilitate the exchange of information between appropriate parties B. Minimize the opportunity for this information to be assessed inappropriately C. Ensure the client's right to have his medical information regarded as personal and confidential D. Guarantee that the information will be shared with only those requiring it for client care purposes

Ensure the client's right to have his medical information regarded as personal and confidential

The nurse realizes that in order to share information from a client's medical record with another facility, the client must provide written consent. The primary reason for this requirement is to:

Ensure the clients right to have his medical information regarded as personal and confidential

Explain how you would document a patient's nursing diagnoses.

Enter them either on the written plan of care or in the agency's electronic health information record. List nursing diagnosis chronically, placing the highest priority nursing diagnosis first; date the diagnosis at time of entry; review the list; and reevaluate the priority.

The nurse reviews data regarding a client's pain symptoms, comparing the defining characteristics for Acute pain with those for Chronic pain. In the end the nurse selects Acute pain as the correct diagnosis. This is an example of avoiding which type of error? A) Error in data clustering B) Error in data collection C) Error in data interpretation D) Error in making a diagnostic statement"

Error in making a diagnostic statement"

A nurse's personal moral code is to assist all patients to the best of her ability. What blended skill would she use when seeking out special services for a homeless patient with a diabetic foot ulcer? A. Cognitive B. Technical C. Interpersonal D. Ethical/Legal

Ethical/Legal

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

Etiology

knowledge based on research or clinical expertise, makes you an informed critical thinker

Evidence based knowledge

A patient is being discharged after abdominal surgery. The abdominal incision is healing well with no signs of redness or irritation. Following instruction, the patient has demonstrated effective care of the incision, including cleansing the wound and applying dressings correctly to the nurse. These behaviors are an example of: 1. Evaluative measure. 2. Expected outcome. 3. Reassessment. 4. Standard of care.

Expected outcome.

A client requires urinary catheterization but has difficulty keeping her legs in the usual position needed for this procedure. The nurse has worked for many years and adapts the procedure to allow the client to lie on her side. This action is based on the critical thinking element of:

Experience

A client requires urinary catheterization but has difficulty keeping her legs in the usual position needed for this procedure. The nurse has worked for many years and adapts the procedure to allow the client to lie on her side. This action is based on the critical thinking element of: 1. Curiosity 2. Experience 3. Perseverance 4. Scientific knowledge

Experience

The second component of critical thinking in the "critical thinking model" is: 1. Experience 2. Competencies 3. Specific knowledge 4. Diagnostic reasoning

Experience

The second component of critical thinking in the critical thinking model is:

Experience

__________ nurses look at the whole picture and use pattern recognition and intuition derived from their experiences to make judgements.

Expert

A patient continues to report postsurgical 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.

Explore other options for pain relief.

One of the purposes of the use of standard formal nursing diagnostic statements is to: A) Evaluate nursing care. B) Gather information on client data. C) Help nurses to focus on the role of nursing in client care. D) Facilitate understanding of client problems by different health care providers."

Facilitate understanding of client problems by different health care providers."

Tell whether the following statement is true or false. Critical thinking occurs when a nurse directly apprehends a situation based on its similarity or dissimilarity to other situations. A. True B. False

False

The nurse summarizes the conversation with the patient to determine if the patient has understood him or her. This is what element of the communication process? A) Referent B) Channel C) Environment D) Feedback

Feedback

The nurse summarizes the conversation with the patient to determine if the patient has understood him or her. This is what element of the communication process? A. Referent B. Channel C. Environment D. Feedback

Feedback

assessment

First step of the nursing process. Activities required in the first step are data collection, validation, sorting, and documentation. The purpose is to gather information for health problem identification.

Nursing diagnostic process

Flows from the assessment process and includes data clustering, interpreting and analyzing, identifying patient needs, and formulating the nursing diagnosis or collaborative problem.

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.

Focus on the patient's presenting situation.

A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse:

Formulates a diagnosis too closely resembling a medical diagnosis

A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse: A. Validates the assessment information in the data base B. Uses the NANDA International list of diagnoses as a primary source C. Formulates a diagnosis too closely resembling a medical diagnosis D. Distinguishes the nursing focus instead of other health care disciplines

Formulates a diagnosis too closely resembling a medical diagnosis

A diagnostic error can influence the application of the nursing care plan. A likely source for a nursing diagnosis error is if the nurse: 1. Validates the assessment information in the data base 2. Uses the NANDA International list of diagnoses as a primary source 3. Formulates a diagnosis too closely resembling a medical diagnosis 4. Distinguishes the nursing focus instead of other health care disciplines

Formulates a diagnosis too closely resembling a medical diagnosis

Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The intervention statement Nurse will apply warm, wet soaks to the patient's leg while awake lacks which of the following components?

Frequency

A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurse's mentor?

Frequently checking the time while waiting for the client to answer

A nurse is observed conducting an assessment interview for a newly admitted client. Which of the following would require immediate follow-up by the nurse's mentor? A. Conducting the interview with the client's boyfriend present B. Stopping the interview to answer a page from the nursing station C. Frequently checking the time while waiting for the client to answer D. Heard asking the client, "Am I correct; you've rated your pain a 9 out of 10?"

Frequently checking the time while waiting for the client to answer

Method of patient care delivery in which each staff member is assigned a task that is completed for all patients on the unit

Functional Health Patterns

Several nurses on an adolescent psychiatric unit complain that the teens are becoming unmanageable on the 0700-1900 shift. To resolve this problem, the nurse manager decides that the staff should have a brainstorming session. The goal of brainstorming is to: a. Evaluate problem solutions. b. Critique the ideas of others. c. Generate as many solutions as possible. d. Identify only practical and realistic ideas.

Generate as many solutions as possible.

The nurse formulates a diagnosis of knowledge deficit related to complications of pregnancy. One outcome criterion is that the client can state five symptoms that indicate a possible problem that should be reported. The client is able to tell the nurse three symptoms. The evaluation statement would be: a. Goal met; client able to state three symptoms b. Goal not met; client able to list three symptoms c. Goal not met; client unable to list five symptoms d. Goal partially met; client able to state three symptoms

Goal partially met; client able to state three symptoms

two ways to complete assessment:

Gordon's Typology and Problem Oriented

The nurse has completed an assessment and found that the client has "an activity and exercise abnormality." This type of wording indicates that which of the following organizing formats has been used? A. Review of systems B. Nursing health history C. Gordon's functional health patterns D. Biographical information database

Gordon's functional health patterns

The nurse has completed an assessment and found that the client has an activity and exercise abnormality. This type of wording indicates that which of the following organizing formats has been used?

Gordons functional health patterns

The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who:

Has a documented blood pressure of 90/50

The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who: 1. Has a documented blood pressure of 90/50 2. Was medicated for back pain 10 minutes ago 3. Has an order to be out of bed and ambulated 4. Requires instructions for wound care before discharge

Has a documented blood pressure of 90/50

NANDA International

Has developed a model for organizing nursing diagnoses for documentation, auditing, and communication purposes.

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? 1 Value-belief pattern 2 Cognitive-perceptual pattern 3 Coping-stress-tolerance pattern 4 Health perception-health management pattern

Health perception-health management pattern

A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses the inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess? 1 Health perception-health management pattern 2 Value-belief pattern 3 Cognitive-perceptual pattern 4 Coping-stress tolerance pattern

Health perception-health management pattern

The nursing diagnosis readiness for enhanced communication is an example of a(n): A) Risk nursing diagnosis. B) Actual nursing diagnosis. C) Health promotion nursing diagnosis D) Wellness nursing diagnosis.

Health promotion nursing diagnosis

From the information supplied in this chapter, which statement best defines critical thinking? Critical thinking is a: a. High-level cognitive process. b. Process that helps to develop reflective criticism for the purpose of reaching a conclusion. c. High-level cognitive process that includes creativity, problem solving, and decision making. d. Discussion that guides the nursing process.

High-level cognitive process that includes creativity, problem solving, and decision making.

Which of the following statements made by a nurse regarding personal reflection related to client care requires follow-up by the unit's nurse manager?

I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4.

Which of the following statements best reflects the nurses correct understanding of the importance of selecting the optimum time for interviewing a client newly admitted to the unit?

I have some questions to ask you regarding your admission history. I'll be back once you are settled in and comfortable.

Which of the following statements made by a nursing student concerning the use of critical thinking and client care requires follow-up by the nursing instructor?

I trust my feelings about a client's needs since I work hard at knowing my client.

The purpose and distinction of a concept map, which a nurse may use when implementing a plan of care, are for:

Identification of the relationship of client problems and interventions

The first part of the nursing diagnosis statement: a. May be stated as a medical diagnosis b. Identifies the cause of the patient problem. c. Identifies appropriate nursing interventions d. Identifies an actual or potential health problem.

Identifies an actual or potential health problem.

Diagnosis

Identify client's problems

Objective for collecting health history

Identify patterns of health, illness, and risk factors

The nurse uses nursing diagnoses after completion of the client assessment, because they:

Identify the domain and focus of nursing

The nurse uses nursing diagnoses after completion of the client assessment, because they: A. Are required for accreditation purposes B. Identify the domain and focus of nursing C. Assist the nurse to distinguish medical from nursing problems D. Make all client problems become more quickly and easily resolved

Identify the domain and focus of nursing

The nurse uses nursing diagnoses after completion of the client assessment, because they: 1. Are required for accreditation purposes 2. Identify the domain and focus of nursing 3. Assist the nurse to distinguish medical from nursing problems 4. Make all client problems become more quickly and easily resolved

Identify the domain and focus of nursing

The risk manager informs the nurse manager of an orthopedic unit that her unit has had an increase in incident reports about patients falling during the 11-7 shift. The nurse manager knows that the best way to resolve the problem is to: a. Use creativity. b. Obtain support from the 7-3 shift. c. Use institutional research. d. Identify the problem.

Identify the problem

The risk manager wants to evaluate the reasons for an increased number of falls on the rehab unit. The risk manager devises a fishbone diagram. A fishbone diagram is a useful tool to: a. Identify the root causes of problems. b. List possible solutions to problems. c. Help leaders select the best options. d. Evaluate the outcomes of decisions made.

Identify the root causes of problems.

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

Identifying patient needs Determining priorities of care Setting goals Performing nursing interventions

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: A) Identifying the clinical sign instead of an etiology. B) Identifying a diagnosis based on prejudicial judgment. C) Identifying the diagnostic study rather than a problem caused by the diagnostic study. D) Identifying the medical diagnosis instead of the patient's response to the diagnosis.

Identifying the medical diagnosis instead of the patient's response to the diagnosis.

A new nurse asks the charge nurse, "How do I know what I can and cannot delegate?" What is the best reply for the charge nurse to give the new nurse? A. "If you follow the five rights of medication administration, you should be fine." B. If you review our state's list of standards, laws, and guidelines for delegation, they will guide you. It is nice to know every state has a list of standards, laws. and guidelines for delegation." C. "You will not be delegating; only the charge nurse delegates. so there is nothing to worry about." D. "Delegation takes time and practice to learn what you can and cannot delegate."

If you review our state's list of standards, laws, and guidelines for delegation, they will guide you. It is nice to know every state has a list of standards, laws. and guidelines for delegation."

The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur?

Impaired gas exchange

The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur? A. Impaired gas exchange B. Decreased cardiac output C. Ineffective airway clearance D. Impaired spontaneous ventilation

Impaired gas exchange

The nurse is concerned that atelectasis may develop as a postoperative complication. Which of the following is an appropriate diagnostic label for this problem, should it occur? 1. Impaired gas exchange 2. Decreased cardiac output 3. Ineffective airway clearance 4. Impaired spontaneous ventilation

Impaired gas exchange

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

Impaired gas exchange related to alveolar-capillary membrane changes

Which of the following is the correctly stated nursing diagnosis? a. Needs to be fed related to broken right arm b. Impaired skin integrity related to fecal incontinence c. Abnormal breath sounds caused by weak cough reflex d. Impaired physical mobility related to rheumatoid arthritis.

Impaired skin integrity related to fecal incontinence

The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address?

Implementation

The nurse decides to administer tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address? 1. Assessment 2. Nursing diagnosis 3. Planning 4. Implementation

Implementation

The fundamental goal for the development of a protocol for care of a client who has had a myocardial infarction client is to: a. Implement care that has its basis in evidence-based practice b. Produce care plans that are specific to the individual client needs c. Improve the standard of care provided to the clients cared for on that unit d. Provide the staff on that unit with guidelines to ensure the delivery of quality care

Improve the standard of care provided to the clients cared for on that unit

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

Improves a plan of care while thinking back on interventions performed

In which of the following cases is the nursing process applicable? a. When nurses work with patients who are able to participate in their care b. When families are clearly supportive & wish to participate in care c. When patients are totally dependent on the nurse for care d. In all the nursing situations listed above

In all the nursing situations listed above

Identify the sources of error in the steps of the nursing process related to errors in interpretation and analysis of data.

Inaccurate interpretation, failure to consider conflicting cues, insufficient number of cues, invalid cues, failure to consider cultural influences.

Which of the following is an appropriate etiology for a nursing diagnosis?

Incisional pain

Which of the following is an appropriate etiology for a nursing diagnosis? A. Incisional pain B. Poor hygienic practices C. Need to offer bedpan frequently D. Inadequate prescription of medication

Incisional pain

Which of the following is an appropriate etiology for a nursing diagnosis? 1. Incisional pain 2. Poor hygienic practices 3. Need to offer bedpan frequently 4. Inadequate prescription of medication

Incisional pain

What is the most appropriate method for the nurse to communicate a client's wishes to the nurses on the next shift? A. Document the request in the nursing notes. B. Include the client's request in the shift report. C. Place instructions regarding the client's wishes above the client's bed. D. Verbally inform the unit clerk of the client's request.

Include the client's request in the shift report.

What is the most appropriate method for the nurse to communicate a client's wishes to the nurses on the next shift?

Include the clients request in the shift report.

Health history

Includes information about his or her physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and expectations about the health care system.

Which one of the following is an appropriate etiology for a nursing diagnosis? A. Myocardial infarction B. Cardiac catheterization C. Abnormal blood gas levels D. Increased airway secretions

Increased airway secretions

Which one of the following is an appropriate etiology for a nursing diagnosis? 1. Myocardial infarction 2. Cardiac catheterization 3. Abnormal blood gas levels 4. Increased airway secretions

Increased airway secretions

Based on the following information, what would the nurse identify as the most appropriate nursing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate. 1. Risk for injury 2. Excess fluid volume 3. Ineffective airway clearance 4. Impaired spontaneous ventilation

Ineffective airway clearance

Based on the following information, what would the nurse identify as the most appropriate nursing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate.

Ineffective airway clearance

Based on the following information, what would the nurse identify as the most appropriate nursing diagnosis? The client has abnormal breath sounds, dyspnea, an intermittent cough, and variable respiratory rate. A. Risk for injury B. Excess fluid volume C. Ineffective airway clearance D. Impaired spontaneous ventilation

Ineffective airway clearance

Of the following statements, which one is an example of an appropriately written nursing diagnosis?

Ineffective airway clearance related to increased secretions

Of the following statements, which one is an example of an appropriately written nursing diagnosis? 1. Risk for change in body image related to cancer 2. Cardiac output decreased related to motor vehicle accident 3. Ineffective airway clearance related to increased secretions 4. Potential for injury related to improper teaching in the use of crutches

Ineffective airway clearance related to increased secretions

Of the following statements, which one is an example of an appropriately written nursing diagnosis? A. Risk for change in body image related to cancer B. Cardiac output decreased related to motor vehicle accident C. Ineffective airway clearance related to increased secretions D. Potential for injury related to improper teaching in the use of crutches

Ineffective airway clearance related to increased secretions

is your judgement or interpretation of these cues

Inference

the process of drawing conclusions from related pieces of evidence and previous experience with the evidence

Inference

Cue

Information that you obtain through use of the senses.

Database

Information. A structures set of data held in a computer.

The nurse has determined the following outcome for a client with a skin impairment: "Erythema will be reduced in 3 days." Evaluation will specifically focus on: a. Selection of appropriate wound care b. Notation of the odor and color of drainage c. Inspection of the color and condition of the area d. Measurement of the diameter of the ulceration daily

Inspection of the color and condition of the area

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.

Institutional practice guidelines.

Identify the sources of error in the steps of the nursing process related to errors in data clustering.

Insufficient cluster or cues, premature or early closure, incorrect clustering.

Collaborative interventions

Interdependent nursing interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.

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

Interpretation

Data analysis

Interpretation, involve recognizing patterns or trends in the clustered data comparing them with standards, and coming to a reasoned conclusion about the patient's response to a health problem.

Describe characteristics of a critical thinker

Interpretation-categorize data Analysis-open minded Inference-look for significant findings Evaluation-Look at situation objectively Explanation-Support your findings Self-regulation-Reflect on your experience

__________ is the process of assembling information to make sense of it.

Interpreting

Which of the following nursing actions should be initiated first when dealing with the following unmet client goal: "Client will lose 10 pounds in 3 months?" a. Interview the client to identify reasons why the goal was not met. b. Assess the client for possible physical reasons for failure to lose the weight. c. Discuss with the client whether they were truly motivated to lose the weight. d. Re-evaluate whether it was realistic for the client to lose 10 pounds in 3 months.

Interview the client to identify reasons why the goal was not met.

The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is "not right" with the client and proceeds to take the vital signs. This is the nurse acting on: 1. Intuition 2. Reflection 3. Knowledge 4. Scientific methodology

Intuition

The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is not right with the client and proceeds to take the vital signs. This is the nurse acting on:

Intuition

The nurse manager of a rehab unit wants to purchase a new anti-embolic stocking. To make a high-quality decision, the nurse manager would: a. Involve the rehab staff in the decision. b. Involve the sales representative. c. Make the decision alone. d. Involve administration in the decision.

Involve the rehab staff in the decision.

Planning

Involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions.

Nursing interventions should be documented according to specific criteria in order that they may be clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is:

Irrigate the nasogastric tube q2h with 30 ml normal saline

Goal

Is a broad statement that describes a desired change in a patient's condition or behavior.

Nursing diagnosis

Is a clinical judgement about individual, family, or community responses to actual or potential health problems or life processes that the nurse is licensed and competent to treat.

Nursing process

Is a critical thinking process that professional nurses use to apply the best available evidence to care giving and the promotion of human functions and responses to health and illness.

Counseling

Is a direct care method that helps patients use a problem-solving process to recognize and manage stress and facilitate interpersonal relationships.

Nursing-sensitive outcome

Is a measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing interventions.

Standing order

Is a pre-printed document containing orders for conducting routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems.

Consultation

Is a process in which you seek expertise of a specialist such as your nursing instructor or a clinical nurse specialist to identify ways to handle problems in patient care management or plan implementation of therapies.

Data cluster

Is a set of signs or symptoms gathered during assessment that you group together in a logical way.

A nursing diagnosis: a. Identifies nursing problems. b. Is not changed during the course of a patient's hospitalization. c. Is derived form the physician's history and physical examination. d. Is a statement of a patient response to a health problem that requires nursing intervention.

Is a statement of a patient response to a health problem that requires nursing intervention.

Clinical practice guideline

Is a systematically developed set of statements that helps nurses and other health care providers make decisions about appropriate health care for specific clinical situations.

Etiology

Is always within the domain of nursing practice and a condition that responds to nursing interventions.

Collaborative problem

Is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patients status.

Nursing intervention

Is any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes.

The second part of the nursing diagnosis statement: a. Is usually stated as a medical diagnosis b. Identifies the expected outcomes of nursing care c. Identifies the probable cause of the patient problem d. Is connected to the first part of the statement with the phrase "related to".

Is connected to the first part of the statement with the phrase "related to".

Related factor

Is identified from the patient's assessment data and is the reason the person is displaying the nursing diagnosis.

Assessment

Is the deliberate and systematic collection of data about a patient.

Medical diagnosis

Is the identification of a disease condition based on an evaluation of physical signs, symptoms, and diagnostic tests and procedures.

Implementation

Is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care.

When asked to define Nursing Diagnosis the nurse's best response is:

It correlates a client's problem with a condition a nurse is competent to treat.

Discuss how reflection improves clinical decisioni making

It will help you become aware of how you used clinical decision-making skills and understand the experience and develop the ability to apply theory in practice

Describe the components of critical thinking model for clinical decision making

Knowledge base, experience, critical thinking competencies, attitudes ,and standards

Evidence-Based Knowledge

Knowledge based on research or clinical expertise, makes you an informed critical thinker

__________ have a license and may give medications but may not assess, teach or evaluate

LPN

When calling a nurse consultant about a difficult client-centered problem, which of the following should the primary nurse report? A) Client's concern about the current treatment B) Length of time current treatment has been in place C) Spouse's reaction to the client's current treatment D) Physician's reluctance to change the current treatment plan"

Length of time current treatment has been in place

Open-ended questions

Long response, more than yes or no. Prompts patients to describe a situation in more than one or two words.

Evaluation

Look at all situations objectively. Use criteria (e.g., expected outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect on your own behavior.

Inference

Look at the meaning and significance of findings. Draw conclusions!! Are there relationships between findings? Do the data about the patient help you see that a problem exists?

Creativity

Look for different approaches if interventions are not working for a patient. For example, a patient in pain may need a different positioning or distraction technique. When appropriate, involve the patient's family in adapting your approaches to care methods used at home.

The nurse is working with a client who is being prepared for a diagnostic test this afternoon. The client tells the nurse that she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to prioritizing her request?

Low priority

The client has a nursing diagnosis of impaired gas exchange as a result of excessive secretions. An outcome for the client is that the airways will be free of secretions. A positive evaluation will focus upon the client's: a. Respiratory rate b. Complaint of chest pain c. Lungs clear bilaterally on auscultation d. Ability to perform incentive spirometry

Lungs clear bilaterally on auscultation

Outcomes management

Managing the individual clinical outcomes of clients as a result of prescribed treatments

The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of interpretation? 1. Evaluating the patient's response to selected nursing interventions 2. Selecting an observable or measurable state or behavior that reflects goal achievement 3. Reviewing the patient's nursing diagnoses and establishing goals and outcome statements 4. Matching the results of evaluative measures with expected outcomes to determine patient's status

Matching the results of evaluative measures with expected outcomes to determine patient's status

By comparing the client's actual response (e.g., behaviors and physiological signs and symptoms) to nursing interventions with expected outcomes established during planning, you determine if goals of care are

Met

The client is scheduled to receive Coumadin (an anticoagulant) at 9:00 AM. His morning laboratory results show him to have a high partial thromboplastin time (PTT). His nurse decides to withhold the Coumadin. Which step of the implementation process is she using? a. Reassessing the client b. Stating an expected outcome c. Revising the nursing diagnosis d. Modifying the nursing care plan

Modifying the nursing care plan

The nurse's initial responsibility in the management of a client's collaborative problem is to:

Monitor for changes

The nurse's initial responsibility in the management of a client's collaborative problem is to: A. Monitor for changes B. Advocate for the client C. Implement interventions D. Evaluate client outcomes

Monitor for changes

The nurse's initial responsibility in the management of a client's collaborative problem is to: 1. Monitor for changes 2. Advocate for the client 3. Implement interventions 4. Evaluate client outcomes

Monitor for changes

You are caring for an 80-year-old woman, and you ask her a question while you are across the room washing your hands. She does not answer. What is your next action? A) Leave the room quietly since she evidently does not want to be bothered right now B) Repeat the question in a loud voice, speaking very slowly C) Move to her bedside, get her attention, and repeat the question while facing her D) Bring her a communication board so she can express her needs

Move to her bedside, get her attention, and repeat the question while facing her

You are caring for an 80-year-old woman, and you ask her a question while you are across the room washing your hands. She does not answer. What is your next action? A. Leave the room quietly since she evidently does not want to be bothered right now B. Repeat the question in a loud voice, speaking very slowly C. Move to her bedside, get her attention, and repeat the question while facing her D. Bring her a communication board so she can express her needs

Move to her bedside, get her attention, and repeat the question while facing her

In documentation of nursing care plans, critical pathways differ from traditional nursing care plans in their:

Multidisciplinary approach

Maturity

Multiple solutions are acceptable. Reflect on your own judgments; have cognitive maturity

Which of the following assessment data provided by a client's family will have the greatest impact on the clients care while hospitalized?

My husband doesn't like to let people know his arthritis is bothering him.

__________ nurses use deductive reasoning, rules, and comparisons of the patient with the textbook in a systemic analysis of the situation.

Novice and less experienced

Independent nursing intervention

Nurse initiated interventions or actions.

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

Nurse's assumptions about hospital discharge

Which of the following statements accurately depicts a step in the critical thinking process? a. The first step when thinking critically is to gather as much data related to the question as possible. b. Nurses who think critically allow emotions to direct their thinking. c. Nurses who use the critical thinking process ultimately must identify alternative decisions & reach a conclusion. d. The critical thinking process is based on intuition & excludes the use of outside resources.

Nurses who use the critical thinking process ultimately must identify alternative decisions & reach a conclusion.

Discuss the relationship of the nursing process to critical thinking

Nursing Process is a systematic, rational method of planning and providing care which requires critical thinking skills to identify and treat actual or potential health problems and to promote wellness. It provides a framework for the nurses to be responsible and accountable.

data collected about a patients present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness

Nursing health history

systematic problem solving method by which nurses individualize care for each patient

Nursing process

Information that can be observed by others

Objective data

A patient has limited mobility as a result of a recent knee replacement. The nurse identifies that he has altered balance and assists him in ambulation. The patient uses a walker presently as part of his therapy. The nurse notes how far the patient is able to walk and then assists him back to his room. Which of the following is an evaluative measure? 1. Uses walker during ambulation 2. Presence of altered balance 3. Limited mobility in lower extremities 4. Observation of distance patient is able to walk

Observation of distance patient is able to walk

A patient with limited English proficiency is going to be discharged on new medication. How does the nurse complete the discharge teaching? A) Uses a dictionary to give directions for medication administration B) Explains the directions to the patient's 14-year-old daughter C) Obtains an interpreter to facilitate communication of medication information D) Uses a picture board and visual aids to communicate medication administration information

Obtains an interpreter to facilitate communication of medication information

A patient with limited English proficiency is going to be discharged on new medication. How does the nurse complete the discharge teaching? A. Uses a dictionary to give directions for medication administration B. Explains the directions to the patient's 14-year-old daughter C. Obtains an interpreter to facilitate communication of medication information D. Uses a picture board and visual aids to communicate medication administration information

Obtains an interpreter to facilitate communication of medication information

form of question that prompts a respondent to answer in more than two words

Opened ended questions

Justin is a nurse manager in a rehabilitation unit in a small urban center. There is a high turnover rate among rehab-assistants because of the heavy work assignments. Despite his need for staff, Justin decides to review each application thoroughly and interview candidates carefully because he recognizes that it is important to hire staff who can best provide high-quality care and who will fit well with the team. Which of the following decision-making models did Justin use in making his decision? a. Subjective model b. Objective model c. Optimizing model d. Satisficing model

Optimizing model

Parts of a client Interview

Orientation phase Working phase Termination phase

A client interview consists of three phases. The nurse recognizes that those phases are:

Orientation, documentation, database

A client interview consists of three phases. The nurse recognizes that those phases are: a. Orientation, working, termination b. Introduction, controlling, selection c. Introduction, assessment, conclusion d. Orientation, documentation, database

Orientation, documentation, database

The nurse recognizes that client goals or outcomes should be documented according to specific criterion in order that they are clear and easily understood by other members of the health care team. Of the following, the outcome statement that best meets the established criteria is the following:

Output will be at least 100 mL/hour of clear yellow urine within 24 hours.

Explain the following components of a nursing diagnosis. (PES format)

P= Problem E= Etiology or related factor S= Symptoms or defining characteristics

Based on the following outcome criterion determined by the nurse: "Client will independently complete necessary assessments prior to administration of digoxin (cardiotonic)" the nurse will evaluate the client's ability to: a. Assess the respiratory rate b. Palpate the radial pulse c. Review dietary habits d. Inspect color of the skin

Palpate the radial pulse

The staff working on the unit includes three RN's, and one LPN, and one NAP for 25 patients. What assignment is the most appropriate for the LPN? A. Pass water to all the patients on the unit. B. Pass oral medications to a group of patients. C. Admit a new patient by completing the history and physical. D. obtain a urine sample from a Foley catheter from a patient who is not assigned to them.

Pass oral medications to a group of patients.

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.

Patient expectations

A clinic nurse assesses a patient who reports a loss of appetite and a 15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall and weighs 135 pounds (61.2 kg). She shows signs of depression and does not have a good understanding of foods to eat for proper nutrition. The nurse makes the nursing diagnosis of imbalanced nutrition: less than body requirements related to reduced intake of food. For the goal of, "Patient will return to baseline weight in 3 months," which of the following outcomes would be appropriate? (Select all that apply.) 1. Patient will discuss source of depression by next clinic visit. 2. Patient will achieve a calorie intake of 2400 daily in 2 weeks. 3. Patient will report improvement in appetite in 1 week. 4. Patient will identify food protein sources.

Patient will achieve a calorie intake of 2400 daily in 2 weeks.

A nursing student is talking with one of the staff nurses who works on a surgical unit. The student's care plan is to include nursing-sensitive outcomes for the nursing diagnosis of acute pain. A nursing-sensitive outcome suitable for this diagnosis would be: 1. Patient will achieve pain relief by discharge. 2. Patient will be free of a surgical wound infection by discharge. 3. Patient will report reduced pain severity in 2 days. 4. Patient will describe purpose of pain medicine by discharge.

Patient will report reduced pain severity in 2 days.

A patient is being discharged today. In preparation the nurse removes the intravenous (IV) line from the right arm and documents that the site was "clean and dry with no signs of redness or tenderness." On discharge the nurse reviews the care plan for goals met. Which of the following goals can be evaluated with what you know about this patient? 1. Patient expresses acceptance of health status by day of discharge. 2. Patient's surgical wound will remain free of infection. 3. Patient's IV site will remain free of phlebitis. 4. Patient understands when to call physician to report possible complications.

Patient's IV site will remain free of phlebitis.

A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after her surgery. Because she has an abdominal incision and dressing and a history of diabetes, the nurse has selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal statement for the diagnosis? 1. Patient will remain afebrile to discharge. 2. Patient's wound will remain free of infection by discharge. 3. Patient will receive ordered antibiotic on time over next 3 days. 4. Patient's abdominal incision will be covered with a sterile dressing for 2 days.

Patient's wound will remain free of infection by discharge.

When modifying a care plan to meet a client whose status has changed significantly over the past few days, the nurse should: a. Redevelop the entire client care plan b. Focus on changing the nursing diagnoses and goals c. Perform a complete reassessment of all client factors d. Add more nursing interventions from a standardized plan of care

Perform a complete reassessment of all client factors

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.

Perform a thorough nursing health history.

The nursing diagnosis of acute pain falls under which of the following comfort domain classifications?

Physical comfort

The nursing diagnosis of acute pain falls under which of the following comfort domain classifications? 1. Social comfort 2. Physical comfort 3. Interpersonal comfort 4. Environmental comfort

Physical comfort

The nursing diagnosis of acute pain falls under which of the following comfort domain classifications? A. Social comfort B. Physical comfort C. Interpersonal comfort D. Environmental comfort

Physical comfort

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

Physical examination

Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool?

Placing a client experiencing shortness of breath on oxygen

Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool? 1. Performing a head-to-toe assessment on a new admission 2. Placing a client experiencing shortness of breath on oxygen 3. Arbitrating a complaint between roommates over the television 4. Notifying a provider of a client's allergy to an ordered medication

Placing a client experiencing shortness of breath on oxygen

Back-channeling

Practice of giving positive comments, encouraging the client to give more information.

involves evaluating the solution over time to make sure it is effective

Problem solving

A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment? 1 Agenda setting 2 Problem-focused 3 Objective 4 Use of a structured database format

Problem-focused

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

Problem-oriented assessment

The nurse is working with a client who has recently had a colostomy and is having difficulty using the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of: 1. Inference 2. Management 3. Problem-solving 4. Diagnostic reasoning

Problem-solving

The nurse is working with a client who has recently had a colostomy and is having difficulty using the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of:

Problem-solving

Mrs. Kay comes to the family clinic for birth control. The nurse obtains a health history and performs a pelvic examination and Pap smear. The Nurse is functioning according to

Protocol

The primary reason for the establishment of standing orders is to: a. Provide appropriate nursing autonomy in settings where client needs can change rapidly b. Facilitate adequate care when direct contact with a primary health care provider is not immediately possible c. Allow nurses to provide certain routine therapies without first notifying the primary health care provider d. Afford the client interventions that reflect the appropriate standard of care in the absence of a primary health care provider

Provide appropriate nursing autonomy in settings where client needs can change rapidly

Concept map

Provides a visual representation of the complex level of thinking that nursing care requires. It forms a picture of each patient's diagnoses and the interconnections between the assessment data and nursing interventions associated with the patient problems.

Nursing interventions may be categorized based upon the degree of nursing autonomy. An example of a nurse-initiated intervention is:

Providing client teaching

An enterostomal nurse shows a client's significant other how to assist with the supplies for the ostomy and how to manipulate the ostomy equipment. In demonstrating this technique to the client's significant other, the nurse is using what type of nursing skill? a. Affective b. Cognitive c. Interactive d. Psychomotor

Psychomotor

The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job. Job loss best fits into which of the following categories?

Psychosocial history

The nurse is gathering a nursing health history on the client. The client tells the nurse that he just lost his job. Job loss best fits into which of the following categories? A. Family history B. Psychosocial history C. Biographical history D. Environmental history

Psychosocial history

In goal setting, the nurse is aware that the factor that is associated with available client resources and motivation is:

Realistic

A nurse on a medical-surgical unit has received change-of-shift report and has been assigned to care for four clients. Which of the following client's needs may be assigned to an UAP? A.Feeding a client who was admitted 24 hr ago with aspiration pneumonia B.Reinforcing teaching for a client who is learning to walk using a quad cane C.Reapplying a condom catheter for a client who has urinary incontinence D.Applying a sterile dressing to a pressure ulcer

Reapplying a condom catheter for a client who has urinary incontinence

During the initial phase of implementation you should

Reassess the client to determine whether the proposed nursing action is still appropriate for the client's level of wellness.

The primary purpose of a nursing diagnosis, according to the nurses, is to: A. Support the medical plan of care B. Provide a standardized approach for all clients C. Recognize the client's response to an illness or situation D. Offer the nurse's subjective view of the client's behaviors

Recognize the client's response to an illness or situation

The primary purpose of a nursing diagnosis, according to the nurses, is to: 1. Support the medical plan of care 2. Provide a standardized approach for all clients 3. Recognize the client's response to an illness or situation 4. Offer the nurse's subjective view of the client's behaviors

Recognize the client's response to an illness or situation

Humility

Recognize when you need more information to make a decision. admit to limitations in ur knowledge and skill. Ask registered nurses (RNs) regularly assigned to the area for assistance with approaches to care. YOUR ONLY HUMAN!!!

An example of a cognitive nursing skill is: a. Providing a soothing bed bath b. Communicating with the client and family c. Giving an injection to the client per the physician's orders d. Recognizing the potential complications of a blood transfusion

Recognizing the potential complications of a blood transfusion

After establishing a nursing diagnosis of Acute pain, the nurse develops which of the following appropriate client-centered goals? A) Determine effect of pain intensity on client function. B) Reduce pain intensity to the level of a client rating of 3 or below during the client's hospital stay. C) Encourage client to implement guided imagery when pain begins. D) Administer analgesic 30 minutes before physical therapy treatment."

Reduce pain intensity to the level of a client rating of 3 or below during the client's hospital stay.

The concept of nursing responsibility is best reflected in which of the following nursing actions? 1. Providing accurate and timely documentation regarding an incident resulting in a client fall 2. Suggesting that a client might prefer taking a particular medication at bedtime instead of in the morning 3. Posting a note on the unit Kardex how to best apply a dressing to a skin wound on a particular client 4. Referring to the institution's policy manual when unsure of how to handle a client's complaint regarding a social services consult

Referring to the institution's policy manual when unsure of how to handle a client's complaint regarding a social services consult

The concept of nursing responsibility is best reflected in which of the following nursing actions?

Referring to the institutions policy manual when unsure of how to handle a client's complaint regarding a social services consult

Self-Regulation

Reflect on your experiences. Identify the ways you can improve your own performance. What will make you believe that you have been successful?

Self-regulation

Reflect on your experiences. Identify the ways you can improve your own performance. What will make you believe that you have been successful?

__________ is the process of thinking and learning from experiences.

Reflecting

the process of purposefully thinking back or recalling a situation to discover its purpose or meaning

Reflection

__________ happens in real time while care is occuring

Reflection-in-action

__________ happens after the patient care occurs

Reflection-on-action

The nurse is working with postoperative clients on a surgical unit. One aspect of care is manipulation of the client's environment. This involves the nurse: a. Repositioning the client q2h b Removing clutter from the client's room c. Delegating ambulation of clients to the nursing assistant d. Providing pain medication to the client before a dressing change

Removing clutter from the client's room

When a client-centered goal has not been met in the projected time frame, the most appropriate action by the nurse would be to:

Repeat the entire sequence of the nursing process to discover needed changes

When a client goal is unmet, which of the following nursing actions is most appropriate? a. Reevaluation of the original client goal b. Selection of new but appropriate interventions c. Evaluation of the client's ability and motivation to be compliant d. Repetition of the entire nursing process regarding the nursing diagnosis

Repetition of the entire nursing process regarding the nursing diagnosis

Which one of the following examples demonstrates the critical thinking attitude of responsibility and authority?

Reporting client difficulties

Which one of the following examples demonstrates the critical thinking attitude of responsibility and authority? 1. Reporting client difficulties 2. Offering an alternative approach 3. Looking for a different treatment option 4. Sharing ideas about nursing interventions

Reporting client difficulties

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.

Requiring the nurse to use critical thinking for the highest level of quality nursing care.

A goal specifies the expected behavior or response that indicates: 1. The specific nursing action was completed. 2. The validation of the nurse's physical assessment. 3. The nurse has made the correct nursing diagnoses. 4. Resolution of a nursing diagnosis or maintenance of a healthy state.

Resolution of a nursing diagnosis or maintenance of a healthy state.

__________ is the implementation of actions and interventions, based on patient needs.

Responding

Which one of the following interventions selected by the nurse is classified as Level 2, Domain 2 (Physiological: complex)?

Restoring tissue integrity to areas damaged by friction

The plan of care offers a number of different types of nursing interventions that may be incorporated in. An example of a nurse implemented specific life-saving measure is: a. Administering analgesics b. Restraining a violent client c. Initiating stress-reduction therapy d. Teaching the client how to take his/her pulse rate

Restraining a violent client

Assuming that all of the following are realistic, a long-term goal for a client that is a tailor by trade and has been admitted for eye surgery should include:

Returning to sewing

Psychosocial history

Reveals clients support system (spouse, family members, friends).

While discussing a client's medication history, the client tells the nurse that she thinks she is allergic to a particular type of medication. Which of the following nursing actions has priority in this situation? A. Note the allergy on the client's Kardex. B. Inform the provider of the client's possible allergy. C. Review the client's medical record for confirmation of the allergy. D. Tell the client to have all medications identified before taking them.

Review the client's medical record for confirmation of the allergy.

While discussing a clients medication history, the client tells the nurse that she thinks she is allergic to a particular type of medication. Which of the following nursing actions has priority in this situation?

Review the clients medical record for confirmation of the allergy.

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.

Reviewing the effectiveness of nursing actions.

The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? A) Risk for aspiration B) Acute confusion C) Readiness for enhanced coping D) Sedentary lifestyle

Risk for aspiration

Which one of the following is a NANDA International nursing diagnosis label?

Risk for impaired parenting

Which one of the following is a NANDA International nursing diagnosis label? A. Frequent urination B. Coughing and dyspnea C. Risk for impaired parenting D. Abnormal hygienic care practices

Risk for impaired parenting

Which one of the following is a NANDA International nursing diagnosis label? 1. Frequent urination 2. Coughing and dyspnea 3. Risk for impaired parenting 4. Abnormal hygienic care practices

Risk for impaired parenting

The nurse manager has developed a staff protocol for peer evaluation. The nurses on her surgical unit are nervous about using her instrument. If the nurse manager continues to implement the new strategy, which of the following critical thinking attitudes is she portraying?

Risk-taking

The nurse manager has developed a staff protocol for peer evaluation. The nurses on her surgical unit are nervous about using her instrument. If the nurse manager continues to implement the new strategy, which of the following critical thinking attitudes is she portraying? 1. Humility 2. Risk-taking 3. Accountability 4. Independent thinking

Risk-taking

In a rural hospital, the unit for which you are charge nurse has a particularly busy morning. A 52-year-old patient is complaining of left-sided chest pain and a multiparous patient is about to deliver. A child with asthma is experiencing early signs of an attack. The other RN on the unit is a recent graduate who has not yet been orientated to the labor room and has limited cardiac nursing experience. An unregulated assistant is also available. You must decide which patient situation you will take and where the RN's skills can best be used. Given the limitations in skills and experience, number of staff available, and time constraints, you must make a decision that involves: a. A higher-order thinking process. b. Selecting the best option for reaching a predefined goal. c. Optimizing. d. Satisficing.

Satisficing.

Discuss critical thinking skills used in nursing practice

Scientific Method, Problem Solving, Decision Making, Diagnostic Reasoning and Inference

codified sequence of steps used in the formulation, testing, evaluation, and reporting of scientific ideas

Scientific method

Care plans created by nursing students usually differ from those that are completed by nurses working on client units. An aspect of the plan that is usually included in the students care plan but not in the client's record is:

Scientific rationales

The nurse notes that a narcotic is to be administered "per epidural cath." The nurse; however, does not know how to perform this procedure. Which aspect of the implementation process should be followed? a. Seek assistance b. Reassess the client c. Use interpersonal skills d. Critical decision making

Seek assistance

Truth Seeking

Seek the true meaning of a situation. Be courageous, honest, and objective about asking questions

Truth seeking

Seek the true meaning of a situation. Be courageous, honest, and objective about asking questions.

A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this client's care needs?

She was sleeping when I checked 15 minutes ago. I'll go back in right now.

When working with an older adult, the nurse remembers to avoid: A) Touching the patient. B) Allowing the patient to reminisce. C) Shifting quickly from subject to subject. D) Asking the patient how he or she feels.

Shifting quickly from subject to subject.

When working with an older adult, the nurse remembers to avoid: A. Touching the patient. B. Allowing the patient to reminisce. C. Shifting quickly from subject to subject. D. Asking the patient how he or she feels.

Shifting quickly from subject to subject.

Instrumental activities of daily living (IADLs) include:

Shopping, preparing meals, writing checks, and taking medications.

Closed-ended questions

Short response, using yes or no. That limit his or her answers to one or two words or a number or frequency of symptoms.

The nurse has become incredibly busy with discharging two patients and expecting a new admission any minute. The following list is tasks that need to be complete right away for the group of patients. What task can be delegated to the NAP to best assist the nurse in managing patient care? A. Remove sutures and drain from an incision on left wrist of the patient to be discharged. B. Provide tracheotomy care on one of the patients C. Sit with patient recently diagnosed with Crohn's disease who is crying. D. Transport a patient to X-ray on cardiac monitor.

Sit with patient recently diagnosed with Crohn's disease who is crying.

A nurse is providing care for a client receiving normal saline when the IV infiltrates. Which of the following nursing actions represents the evaluation phase of the nursing process? a. IV is discontinued. b. Warm compress applied to IV site. c. Site reinspected for presence of swelling. d. IV site observed as having significant swelling.

Site reinspected for presence of swelling.

The nurse is best demonstrating perseverance by:

Sitting with a client until she is ready to discuss why she is crying

The nurse is best demonstrating perseverance by: 1. Having a perfect attendance record 2. Completing a lengthy course on current chemotherapies 3. Repeatedly irrigating the nasogastric tube until it is patent 4. Sitting with a client until she is ready to discuss why she is crying

Sitting with a client until she is ready to discuss why she is crying

To provide optimum care, a nursing intervention should be based on: a. An appropriate nursing diagnosis b. Subjective and objective client data c. Sound clinical judgment and knowledge d. Identified physical and psychosocial needs of the client

Sound clinical judgment and knowledge

Match the activity on the left with the source of diagnostic error on the right: Activity a. Nurse listens to lungs for first time and is not sure if abnormal lung sounds are present. b. After reviewing objective data, nurse selects diagnosis of fear before asking patient to discuss feelings. c. Nurse identifies incorrect diagnostic label. d. Nurse does not consider patient's cultural background when reviewing cues. e. Nurse prepares to complete decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern.

Source of Diagnostic Error __ 1. Collecting data __ 2. Interpreting __ 3. Clustering __ 4. Labeling 1 a, 2 b d, 3 e, 4 c

After visiting with the client, the nurse documents the assessment data. Both objective and subjective information have been obtained during the assessment. Which of the following is classified as subjective data?

States feels anxious and tense

Types of Data

Subjective data & Objective data

A client shares with the nurse that they have, "almost reached the goal of smoking only one-half pack of cigarettes a day." The best example of a nursing intervention to correct this unmet outcome is: a. Discuss with the client the desire to comply with the ordered therapy b. Suggest that the client use another smoking cessation tool to achieve the goal c. Reevaluate the time frame originally decided upon for achievement of the goal d. Suggest that the strength of the prescribed nicotine patches be increased to 21 mg

Suggest that the strength of the prescribed nicotine patches be increased to 21 mg

Explanation

Support your findings and conclusions. Use knowledge and experience to choose strategies to use in the care of patients.

If the nurse informs the health care provider of his or her lack of preparation in carrying out a prescription or order, and carries out the prescription or order anyway who is liable....

THE NURSE AND THE HEALTH CARE PROVIDER ARE LIABLE FOR ANY DAMAGES

If the nurse carries out a health care provider's prescription or order for which he or she is not prepared, and does not inform the health care provider of his or her lack of preparation who is liable for the damages?

THE NURSE IS SOLELY LIABLE FOR ANY DAMAGES.

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.

Take immediate action when a patient's condition worsens.

You are caring for Mr. Smith, who is facing amputation of his leg. During the orientation phase of the relationship, what would you do? A) Summarize what you have talked about in the previous sessions B) Review his medical record and talk to other nurses about how he is reacting C) Explore his feelings about losing his leg D) Talk with him about his favorite hobbies

Talk with him about his favorite hobbies

Thinking independently

Talk with other nurses and share ideas about nursing interventions. making sense based on your own observations and experiences rather than just depending on the word of others; trusting your own ability to make judgments, even if they contradict what others say; acting in accordance with these judgments, even if you sometimes make mistakes. An independent thinker knows it's psychologically better to make your own mistakes than someone else's.

Which of the following interventions best reflects the nurse's understanding of direct care interventions regarding a cognitively impaired client's need for social interaction? a. Arranging for the client to attend a "sing along" in the dayroom b. Helping the client place a long distance telephone call to his daughter c. Turning the client's television on when his or her favorite program is playing d. Talking about the client's favorite sport's team while redressing his or her wound

Talking about the client's favorite sport's team while redressing his or her wound

Mary Jones is a newly diagnosed diabetic client. The nurse shows Mary how to administer an injection. This intervention activity is:

Teaching

The nurse is deciding on the type of dressing to use for a client. Which step of the decision- making process is being used when the nurse observes the absorbency of different dressing brands?

Testing possible options

The nurse is deciding on the type of dressing to use for a client. Which step of the decision-making process is being used when the nurse observes the absorbency of different dressing brands? 1. Defining the problem 2. Making final decisions 3. Testing possible options 4. Considering consequences

Testing possible options

Validation

The action of checking or proving the validity or accuracy of something.

When following up on a client's report of hip pain during an admission assessment, the most nursing conclusive observation would be: A. The client tearing when being ambulated to the chair B. A report from the ancillary staff that the client is reporting pain C. The client observed grimacing when positioning self in the bed D. Overhearing the client discuss hip pain with family on the phone

The client observed grimacing when positioning self in the bed

When following up on a clients report of hip pain during an admission assessment, the most nursing conclusive observation would be:

The client observed grimacing when positioning self in the bed

Which of the following is an example of a nurse's statement that reflects using the scientific method in the nursing process?

The client reports more pain than yesterday, and her blood pressure is elevated.

The nurse caring for an immobile client with a pressure ulcer implements an intervention that requires repositioning the client every 2 hours. Which of the following represents the best evaluation method for this intervention? a. No additional pressure ulcers are noted over a 1-week period. b. Client expresses a decrease in pressure ulcer related pain within 1 week. c. The client's pressure ulcer shows a decrease in size over a 1-week period. d. The turning schedule is initiated to reflect appropriate positioning for a 1-week period.

The client's pressure ulcer shows a decrease in size over a 1-week period.

The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses?

The diagnosis should include the problem and the related contributing conditions.

The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses? A. The diagnosis should identify a "cause and effect" relationship. B. The diagnosis must remain constant during the client's hospitalization. C. The etiology of the diagnosis must be within the scope of the health care team's practice. D. The diagnosis should include the problem and the related contributing conditions.

The diagnosis should include the problem and the related contributing conditions.

The nurse recognizes that which one of the following statements is true with regard to the formulation of nursing diagnoses? 1. The diagnosis should identify a "cause and effect" relationship. 2. The diagnosis must remain constant during the client's hospitalization. 3. The etiology of the diagnosis must be within the scope of the health care team's practice. 4. The diagnosis should include the problem and the related contributing conditions.

The diagnosis should include the problem and the related contributing conditions.

Interventions:

The evaluation of interventions examines two factors: the appropriateness of the intervention selected and the correct application of the intervention. Appropriateness is based on the standard of care for a patient's health problem.

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.

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.

Which of the following nursing actions best reflects the consequence stage of the decision-making process?

The nurse explains to the client the risks of leaving the hospital against medical advice.

Which of the following nursing actions best reflects the consequence stage of the decision-making process? 1. Being physically present when a client is given the results of a tissue biopsy 2. Witnessing the client sign consent for surgery forms before cardiac surgery 3. The client is informed of the various treatments available for his condition. 4. The nurse explains to the client the risks of leaving the hospital against medical advice.

The nurse explains to the client the risks of leaving the hospital against medical advice.

Which of the following nursing situations best reflects accountability?

The nurse files an incident report regarding a medication error.

Which of the following nursing situations best reflects accountability? 1. The nurse takes the oncology nursing certification examination. 2. The nurse files an incident report regarding a medication error. 3. The nurse assesses the client for the possible cause of his pain. 4. The nurse tells the client, "I don't know but I will find out for you."

The nurse files an incident report regarding a medication error.

The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest? 1 The nurse is making an accurate clinical inference. 2 The nurse has gathered cues to identify a potential problem area. 3 The nurse has allowed stereotyping to influence her assessment. 4 The nurse wants to validate her information with the other nurse.

The nurse has allowed stereotyping to influence her assessment.

In the examples given below, which nurse is acting to avoid a data collection error? A) The nurse asks her colleague to chart her assessment data. B) The nurse considers conflicting cues in deciding on the correct nursing diagnosis. C) The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her. D) After performing an assessment the nurse critically reviews his level of comfort and competence with interviewing and physical assessment skills."

The nurse who assesses the edema in a client's lower leg is unsure of its severity and asks her co-worker to check it with her.

Which of the following statements concerning the nursing process is accurate? a. The nursing process is nurse-oriented. b. The steps of the nursing process are separate entities. c. The nursing process is' nursing practice in action. d. The nursing process comprises four steps to promote patient well-being.

The nursing process is' nursing practice in action.

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.

The nursing student is speaking only to the patient's daughter.

During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about:

The onset and duration of his present breathing problem

During the admission history, the client states that he has trouble breathing at night. In obtaining data for a problem-oriented database, the nurse should first question the client about: A. The onset and duration of his present breathing problem B. His personal smoking, alcohol use, and exercise practices C. Any extended family members who have diagnosed heart disease D. Changes in other body systems that the client perceives as problematic

The onset and duration of his present breathing problem

The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about:

The onset, severity, and duration of the chest pain

The nurse begins the assessment of a client that has come to the emergency department experiencing chest pain by asking the client about: A. A family history of heart problems B. Medications currently being taken at home C. Questions or concerns about hospitalization D. The onset, severity, and duration of the chest pain

The onset, severity, and duration of the chest pain

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.

The patient is apprehensive about discharge.

The nurse has a patient who is short of breath and calls the health care provider using SBAR (Situation-Background-Assessment-Recommendation) to help with the communication. What does the nurse first address? A) The respiratory rate is 28. B) The patient has a history of lung cancer. C) The patient is short of breath. D) He or she requests an order for a breathing treatment.

The patient is short of breath.

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

The patient's room with the door closed

The statement that best explains the role of collaboration with others for the patient's plan of care is which of the following? A) The professional nurse consults the health care provider for direction in establishing goals for patients. B) The professional nurse depends on the latest literature to complete an excellent plan of care for patients. C) The professional nurse works independently to plan and deliver care and does not depend on other staff for assistance. D) The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

The statement that best explains the role of collaboration with others for the patient's plan of care is which of the following? A. The professional nurse consults the health care provider for direction in establishing goals for patients. B. The professional nurse depends on the latest literature to complete an excellent plan of care for patients. C. The professional nurse works independently to plan and deliver care and does not depend on other staff for assistance. D. The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

The professional nurse works with colleagues and the patient's family to provide combined expertise in planning care.

The client recently became febrile and stated he "felt hot." The nurse takes the client's temperature and finds it to be 38.2° C. In addition, the pulse rate is 88 beats per minute, and his blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data? A. Pulse rate of 88 beats per minute B. Blood pressure of 168/80 mm Hg C. The statement regarding his feeling hot D. The supported fact that he became febrile

The statement regarding his feeling hot

The client recently became febrile and stated he felt hot. The nurse takes the clients temperature and finds it to be 38.2 C. In addition, the pulse rate is 88 beats per minute, and his blood pressure is 168/80 mm Hg. Which of the following is an example of subjective data?

The statement regarding his feeling hot

Discuss the critical thinking attitudes used in clinical decision making

These define how a successful thinker approaches a problem, Knowing when information is misleading and recognizing your own limits are examples how attitudes guide thinking.

Which of the following best reflects the philosophy of critical thinking as taught by a nurse educator to a nursing student?

Think about several interventions that you could use with this client.

A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, "what the diagnosis means." Which of the following rationales best supports the nurse's determination that the client has knowledge deficit rather than a readiness for enhanced knowledge? A. The client initiated the question. B. This is a new diagnosis for the client. C. The client identified a lack of understanding. D. Type 2 diabetes mellitus is a complicated disease process.

This is a new diagnosis for the client.

A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, "what the diagnosis means." Which of the following rationales best supports the nurse's determination that the client has knowledge deficit rather than a readiness for enhanced knowledge? 1. The client initiated the question. 2. This is a new diagnosis for the client. 3. The client identified a lack of understanding. 4. Type 2 diabetes mellitus is a complicated disease process.

This is a new diagnosis for the client.

A client newly diagnosed with type 2 diabetes mellitus asks the nurse to explain, what the diagnosis means. Which of the following rationales best supports the nurse's determination that the client has knowledge deficit rather than a readiness for enhanced knowledge?

This is a new diagnosis for the client.

Which of the following statements best reflects the nurse's understanding of the primary nursing-related purpose of a concept map? A. To facilitate holistic nursing care B. To provide visualization of the client's health problems C. To assist in the identification of client-oriented nursing diagnoses D. To demonstrate the relationship between the client's various health problems

To demonstrate the relationship between the client's various health problems

Which of the following statements best reflects the nurses understanding of the primary nursing-related purpose of a concept map?

To demonstrate the relationship between the client's various health problems

The purpose of conducting evaluative measures is

To determine if you met the expected outcomes, not if the nursing interventions were completed. They are the standards against which the nurse judges if goals have been met and if care is successful

What is the purpose of assessments?

To establish a *database* about the pt's perceived needs, health problems, and responses to the problems

Which of the following responses best reflects an understanding of the purpose of the related to phrase attached to the diagnostic label deficient knowledge regarding postoperative routines?

To provide for individualization of the nursing interventions

The nurse has diagnosed the client's problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except:

Total hip replacement

The nurse has diagnosed the client's problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except: A. Poor fiber intake B. Limited fluid intake C. Total hip replacement D. Lower abdominal discomfort

Total hip replacement

The nurse has diagnosed the client's problem as altered elimination. From the database the nurse identifies all the following as appropriate etiologies for this diagnosis except: 1. Poor fiber intake 2. Limited fluid intake 3. Total hip replacement 4. Lower abdominal discomfort

Total hip replacement

Tell whether the following statement is true or false. Concept mapping is an instructional strategy that requires learners to identify, graphically display, & link key concepts. A. True B. False

True

True or False: Encourage clients to tell stories about illness during assessment

True

Self-confidence

Trust in your own reasoning processes

Which of the following nursing actions is the best example of problem solving?

Trying several difficult wound dressings to determine which one the client can apply the most effectively

Which of the following nursing actions is the best example of problem solving? 1. Requesting the IV team to start an antibiotic drip on a client with a history of being a difficult stick 2. Offering to call the kitchen to provide an alternate breakfast for a client who does not like cooked cereal 3. Trying several difficult wound dressings to determine which one the client can apply the most effectively 4. Calling for another pain medication order when the current drug results in the client experiencing nausea

Trying several difficult wound dressings to determine which one the client can apply the most effectively

Which of the following interventions is the best example of an indirect intervention directed towards client safety? a. Checking on a restrained client every 15 minutes b. Performing hand hygiene between client contacts c. Including the diagnosis at risk for injury related to falls to a client's care plan d. Turning on a night light to illuminate the path to the bathroom

Turning on a night light to illuminate the path to the bathroom

An outpatient surgery manager is evaluating infusion pumps for the operating room. The manager should: a. Select the least expensive brand. b. Use a decision-making tool to evaluate brands. c. Ask the nursing staff which brand they prefer. d. Select the vendor the institution usually buys from.

Use a decision-making tool to evaluate brands.

Functional health patterns

Used by nurses in the nursing process to provide a more comprehensive nursing assessment of the patient.

A good nursing decision maker is one who: a. Uses various models to guide the process based on the circumstances of the situation. b. Adopts one model and uses it to guide all decision making. c. Decides not to use any models because they are all useless. d. Develops a new model each time a decision has to be made.

Uses various models to guide the process based on the circumstances of the situation.

The nurse recognizes that a client's hearing deficits impact the development of the nurse-client relationship. Which of the following has the greatest impact on minimizing this obstacle?

Using various forms of nonverbal communication

The nurse recognizes that a client's hearing deficits impact the development of the nurse-client relationship. Which of the following has the greatest impact on minimizing this obstacle? A. Speaking slowly, clearly, and in a normal tone B. Using various forms of nonverbal communication C. Relying heavily on touch to convey caring and interest D. Involving family in discussions concerning meeting client's needs

Using various forms of nonverbal communication

The nursing diagnosis Readiness for enhanced communication is an example of which of the following? A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D)Wellness nursing diagnosis

Wellness nursing diagnosis

Which of the following questions asked by the nurse during the assessment process is best directed towards gathering information regarding the client's depression?

What do you believe is the cause of your depression?

The nurse decides to interview the client using the open-ended question technique. Which of the following statements reflects this type of questioning?

What do you think has been causing your current depression?

Subjective data

What the patient "says". Are patient's verbal descriptions of their health problems.

Objective data

What you "observe". Are observations or measurements of a patient's health status.

An ER nurse is interviewing a client who complains of abdominal pain. Which of the following questions asked by the nurse has priority at this time?

When did your abdominal pain begin?

Modifying a Care Plan:

When goals are not met, you identify the factors that interfere with their achievement. Usually a change in the patient's condition, needs, or abilities makes alteration of the care plan necessary.

Goals and Expected Outcomes:

When revising a care plan, review the goals and expected outcomes for necessary changes. In addition, examine the goals for unchanged nursing diagnoses for their appropriateness because a change in one problem sometimes affects the goals in others.

Identify the sources of error in the steps of the nursing process related to errors in diagnostic statement.

Wrong label, evidence exists for another diagnosis, collaborative problem, failure to validate with the patient, failure to seek guidance.

A new graduate nurse missed cues regarding the client's emotional state at the time of admission. The most therapeutic response to the nurse by her mentor is:

You will be less likely to miss client cues as you acquire more experience with assessments.

Individualized care

__________ is needed in order to give the highest quality care to all patients.

Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living

activity-exercise pattern

Documentation of evaluative findings allows...

all members of the health team to know whether a client is progressing or not

A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, "I feel funny." The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show?

analyticity, self confidence

Which of the following is unique to the commitment level of critical thinking?

anticipates when to make choices without assistance

Evaluative measures:

are the same as assessment measures, but you perform them at the point of care when you make decisions about the patient's status and progress.

__________ may not do any task that requires nursing judgement - assess, teach, evaluate, medications, care of unstable client

assistive personal

Which type of critical thinking is this: "Using a hospital manual to review procedures" A. Basic Critical thinking B. Complex critical thinking C. Commitment

basic

Responsibility and Accountability

being accountable for your own actions; no shortcuts; correctly perform nursing care activities. Ask for help if you are not sure about how to perform an aspect of patient care. Report any problems immediately. Follow standards of practice in your care

Confidence

belief in oneself and one's powers or abilities. Learn how to introduce yourself to a patient; speak with conviction when you begin a treatment or procedure. Do not lead a patient to think that you are unable to perform care safely. Always be well prepared before performing a nursing activity. Encourage a patient to ask questions

This type of questioning helps you acquire specific information about health problems such as symptoms, precipitating factors, or relief measures.

close-ended

What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?"

closed-ended and problem oriented questioning

Form of question that limits a respondent's answer to one or two words:

closed-ended questions

Successful implementation of nursing interventions requires you to use appropriate

cognitive, interpersonal, and psychomotor skills

Describes sensory-perceptual patterns; language adequacy, memory, decision-making ability

cognitive-perceptual pattern

Evaluative measures are assessment skills or techniques that you use to

collect data for evaluation

The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview?

collecting the assessment

Which type of critical thinking is this: "Makes choices without assistance and accepts accountability for decisions made" A. Basic Critical thinking B. Complex critical thinking C. Commitment

commitment

RNs must delegate tasks so that they can...

complete higher level tasks that only RNs can perform.

analyzing and examining choices and weighing benefits and risk are characteristics of

complex critical thinking

a visual representation of patient problems and interventions that shows their relationships to one another

concept map

The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case the finding of nausea is a ____

concomitant symptom

Describes patient's ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance

coping-stress tolerance pattern

clinical decision making involves judgement that includes

critical and reflective thinking and action and application of scientific and practical logic

Decision making is a product of _____ that focuses on problem resolution.

critical thinking

a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant

critical thinking

Explain the relationship between clinical experience and critical thinking

critical thinking skills focus on evaluating alternatives and forming sound judgments, clinical experience helps support your findings and conclusions

During evaluation you should apply

critical thinking to make clinical decisions and redirect nursing care to best meet client needs

Information that a nurse acquires through hearing, visual observations, touch, and smell:

cue

information that you collect through the use of your senses. Ex. pain

cue

Store or bank of information, especially in a form that can be processed by computer:

database

Discuss the nurse's responsibility in making clinical decisions

defining client problems and selecting appropriate treatment. Know your client. Keep them in center focus select therapies most likely to relieve problem

Positive evaluations occur when you meet... and they also lead you to conclude ....

desired outcomes your interventions were effective

It sometimes becomes necessary to collect evaluative measures over time to

determine if a pattern of change exists

the nurse sits down to talk to a patient who lost her sister 2 weeks ago. the patient reports she is unable to sleep, feels very tired during the day, and is having trouble at work. the use asks her to clarify the type of trouble. the patient explains she can't concentrate or even solve simple problems. the use records the results of assessment, describing the patient as having ineffective coping. this is an example of :

diagnostic reasoning

While obtaining a health history, the nurse asks Mr. Jones if he has noted any changes in his activity tolerance. This is an example of which interview technique?

direct question Rationale: some may be focused, and others may be comprehensive

Describes patterns of excretory function (bowel, bladder, and skin)

elimination pattern

Health care organizations are responsible for

evaluating and improving the quality of client care services they provide

secondary source of assessment info

family members, hc professionals, medical record

Fairness

free from bias or injustice; Listen to both sides in any discussion. If a patient or family member complains about a co-worker, listen to the story and then speak with the co-worker as well. If a staff member labels a patient uncooperative, assume the care of that patient with openness and a desire to meet that patient's needs.

Gordon's model =

functional health patterns

Method for organizing assessment data based on the level of patient function in specific areas (e.g., mobility).

functional health patterns

Assessment moves from ____to____.

general to specific

Evaluation:

he final step of the nursing process, is crucial to determine whether, after application of the nursing process, the patient's condition or well-being improves.

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns?

health perception-health management pattern

A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses the inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess?

health perception-health management pattern

Describes patient's self-report of health and well-being; how patient manages health (e.g., frequency of health care provider visits, adherence to therapies at home); knowledge of preventive health practices

health perception-health management pattern

Integrity

honest and willing to admit to mistakes or inconsistencies in your own behavior, ideas and beliefs, but always tries to follow the highest standards of practice

To anticipate and prevent complications, a nurse

identifies risks to the client, adapts interventions to the situation, evaluates the relative benefit of a treatment versus the risk, and initiates risk prevention measures.

Judgment or interpretation of informational cues

inference

your judgement or interpretation of the cues you just gathered (a conclusion)

inference

an organized conversation with the patient

interview

Nursing-sensitive outcome:

is a measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing interventions

Clinical judgement

is an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response.

A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. What response by the nurse is an example of probing?

is anything else bothering you?

Reflection on practice

is often triggered by a breakdown in clinical judgement and is critical for the development of clinical knowledge and improvement in clinical reasoning.

Standard of care:

is the minimum level of care accepted to ensure high quality of care to patients. Standards of care define the types of therapies typically administered to patients with defined problems or needs.

Perseverance

keep looking for more resources until you find a successful approach; not satisfied with a minimal effort but works to achieve the highest possible level of quality care. Ex: pt is unable to speak after throat surg (challenge for nurse) to communicate effectively. Nurse tries diff comm approaches (bell, message board, paper and pen)

To complete any nursing procedure, you need to

know the procedure, its frequency, the steps, and the expected outcomes.

When professional nurses think in terms of outcomes management, their actions become

more purposeful and focused on improving the condition of their client's health

Data collected about a patient's present level of wellness, changes in life patterns, sociocultural role, and mental and emotional reactions to illness.

nursing health history

Systematic problem-solving method by which nurses individualize care for each patient. The five steps of the nursing process are assessment, diagnosis, planning, implementation, and evaluation.

nursing process

Describes patient's daily/weekly pattern of food and fluid intake (e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain.

nutritional-metabolic pattern

Information that can be observed by others; free of feelings, perceptions, prejudices.

objective data

observations or measurements a health care provider obtains. Inspection of a wound, description of an observable behavior. Vital signs, etc

objective data

Gordon's functional health patterns model

offers a holistic framework for assessment of any health problem

the interview technique that is most effective in strengthening the nurse-patient relationship by demonstrating the nurses's willingness to hear the patients thoughts

open-ended Rationale: it prompts patients to describe a situation in more than one or two words

Form of question that prompts a respondent to answer in more than one or two words.

open-ended questions

when collecting the assessment, always open with

open-ended questions

nurses who apply critical thinking in their work focus on

options for solving problems and making decisions rather than rapidly and carelessly forming quick, and single solutions

Interview

organized conversation with the client. *obtain subjective data

primary source of assessment info

patient

is an approach for obtaining from patients the data that are needed to foster a caring nurse-patient relationship, adherence to interventions, and treatment effectiveness. It is the basis of a conceptual model used by nurse practitioners to form long-term therapeutic relationships with patients

patient centered interview

This allows the nurse or patient who is speaking to check whether information is understood. It is a signal for readiness to initiate interaction with a patient. Eye contact shows that you are interested in what the other person is saying.

patient-directed eye gaze

A nurse is looking for __________ that are consistent with previous experiences and uses that information to guide care.

patterns

observation of patient behavior, diagnostic and lab data, interpreting assessment data and making nurse judgments

physical examination

What makes symptoms worse? Are there activities (e.g., exercise) that affect the symptoms?

precipitating factors

A ______ question encourages a full description without trying to control the direction of the patient's story. It requires further open-ended statements.

probing

encourage a full description without trying to control the direction the story takes. This requires you to probe with further open-ended statements such as, "Is there anything else you can tell me?" or "What else is bothering you?"

probing

Mr. Davis tells the nurse that he has been experiencing more frequent episodes of indigestion. The nurse asks if the indigestion is associated with meals or a reclining position and asks what relieves the indigestion. This is an example of which interview technique

problem seeking. Rationale: this takes information provided in the patient's story and then more fully describes and identifies specific problem areas

While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of:

problem solving

A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment?

problem-focused

A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in what assessment approaches at this time?

problem-focused approach and using multiple visits to gather a complete database

approach for conducting a comprehensive assessment where you focus on the patient's presenting situation and being with problematic areas such as incisional pain or limited understanding of postoperative recovery

problem-oriented approach

Explain how professional standards influence a nurse's clinical decisions

requires you to use critical thinking for the good of individuals or groups.It is a reflection of ethical standards. It promotes the highest level of quality nursing care

a systematic approach for collecting the patients self reported data on all body systems

review of systems

is a systematic approach for collecting the patient's self-reported data on all body system

review of systems (ROS)

When a nurse considers delegating a task to assist in the care of patient, what five rights should be utilized? A. right task, right circumstance, right person, right direction/communication, and right supervision. B. right room, right time, right person, right documentation, and right directions. C. right patient, right chart, right physician, right result, and information. D. right person, right patient, right task, right documentation, and right time frame.

right task, right circumstance, right person, right direction/communication, and right supervision.

Describes patient's patterns of role engagements and relationships

role-relationship pattern

Describes patient's self-concept pattern and perceptions of self (e.g., self-concept/worth, emotional patterns, body image)

self-perception-self-concept pattern

steps of an interview

set the stage, set an agenda, collect assessment, terminate the interview

Describes patient's patterns of satisfaction and dissatisfaction with sexuality pattern; patient's reproductive patterns; premenopausal and postmenopausal problems

sexuality-reproductive pattern

Describes patterns of sleep, rest, and relaxation

sleep-rest pattern

The basis of safe and effective nursing practice is the ability to make

sound clinical judgements

The nurse carries a responsibility to the client to be competent, providing nursing care in accordance with...

standards of nursing practice, and adhering to professional codes of ethics.

The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest?

stereotyping influenced her assessment

Information gathered from patient statements; the patient's feelings and perceptions. Not verifiable by another except by inference.

subjective data

patient's verbal descriptions of their own health problems, provided by the patient. Includes feelings, perceptions, self-report of symptoms

subjective data

Review of systems (ROS)

systematic method for collecting data on all body systems

Back channeling

technique used that includes active listening prompts such as: "all right, go on, uh huh"

Act of confirming, verifying, or corroborating the accuracy of assessment data or the appropriateness of the care plan.

validation

Describes patterns of values, beliefs (including spiritual practices), and goals that guide patient's choices or decision

value-belief pattern

Concept Map

visual representation of patient problems and interventions that shows their relationships to one another. Nonlinear picture of a patient that can be used for comprehensive care planning

Reflective Journaling

writing tool for developing critical thought and reflection by clarifying concepts.