EXAM 2: Review Questions

14 - A nurse has just graduated and will be starting a new job in a clinical setting. The nurse states, "I want to be intentional about getting beyond being a novice and eventually progressing to be an expert nurse." Which action will support the nurse's goal? Become familiar with Benner's model of nurse development. Set a future goal for implementing the nursing process during client encounters. Gain knowledge within the QSEN competencies. Advocate publicly for increased visibility of the nursing profession.

Become familiar with Benner's model of nurse development. *Benner's novice-to-expert model specifically informs professional development along this continuum. Nurses of all levels of experience should be applying the nursing process in some form; this should not be characterized as a future goal. Advocacy is beneficial, but the act of advocating does not necessarily lead to professional development. Similarly, becoming familiar with the QSEN competencies will not necessarily help the nurse develop.

13 - Which activity is the clearest example of the evaluation step in the nursing process? Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading Checking the client's blood pressure 30 minutes after administering captopril Recognizing that the client's blood pressure of 172/101 is an abnormal finding Taking a client's blood pressure on both arms at the beginning of a shift

Checking the client's blood pressure 30 minutes after administering captopril

13 - While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking? Precision Clarity Relevance Accuracy

Clarity

13 - The nurse is caring for a client in a critical care unit. The client's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm? Cognitive and technical skills Interpersonal and technical skills Interpersonal and ethical skills Cognitive and ethical skills

Cognitive and technical skills

- comes from data analysis & interpretation - come from assessment - any significant data that raises "red flag" - cues - RN looking for actual or potential nursing problem diagnosis - While determining what is going on with the patient, you need to have strong interpersonal and communication skills. Gain their trust so they can tell you "their story".

Criteria for Nursing Dx

13 - A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. Which behavior is the nurse demonstrating in the care of the client? Reflection in action Critical reflectivity Thoughtful practice Reflective skepticism

Critical reflectivity Critical reflectivity (becoming aware of one's awareness and critiquing it) occurs when a person questions judgments and considers other ways of thinking about the situation. Thoughtful practice is caregiving to promote the humanity, dignity, and well-being of the client. Reflection in action requires the person to engage in exploring experiences to lead to new understandings and appreciations during the situation or during clinical practice. Reflective skepticism involves adopting an attitude of doubt about supposed truths.

14 -A group of student nurses has been encouraged by their instructors to be intentional and deliberate about applying clinical decision-making models to their practice. A student tells a colleague, "The model that makes the most sense to me is the information-processing model, because it seems the most straightforward." How should the colleague best respond to this student? "I agree. The model is elegant for its simplicity and has been clinically linked to better client outcomes." "That model was dominant in nursing for decades but has recently been replaced by more nuanced models." "It is definitely a clear model, but it does not really capture all of the complexities and the human element of nursing." "Absolutely. Many of the other models are evidence-based but excessively complex."

"It is definitely a clear model, but it does not really capture all of the complexities and the human element of nursing." The information-processing model is attractive by virtue of its simplicity and linear nature. However, there is no significant drive to apply this model to nursing practice, because nursing is psychosocially complex and cannot be reduced to a simple equation of input and output. For this reason, it has never been predominant in nursing, even in past decades. It has not been proven to achieve better client outcomes in the literature.

13 - The nurse is caring for a client who has been in the hospital for 7 days. When the nurse enters the room to perform the morning assessment, the client tells the nurse that the client can't wait to go home. Which statement by the nurse demonstrates that the nurse is skilled in developing caring relationships? "Maybe you will get to go home soon." "What do you miss most about being away from home?" "I am really busy this morning, but after my morning rounds I will come back and we can discuss how you feel." "Well, you only have 3 days left before you can go home."

"What do you miss most about being away from home?"

13 - A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask? "Were assumptions made correctly?" "How did the client perceive the event?" "How did the client value the experience?" "What happened?"

"What happened?"

14 - A nursing student observed a staff nurse change a client's IV dressing. During post-conference, the student remarked to a classmate, "The nurse did not even follow the process we learned in lab!" What is the classmate's most appropriate response? "Remember that the end result is the important thing, not the way that it's done." "It is well-known that nurses begin to 'cut corners' as soon as they graduate." "It is best to ignore what you see nurses do in practice and instead focus on what we learned." "You should consider some of the factors that might have influenced the nurse's action."

"You should consider some of the factors that might have influenced the nurse's action." **It is important to consider contextual factors and the underlying principles when reflecting on differences between what the student nurse learns and what the student nurse observes in practice. This does not entail ignoring what is seen in the clinical setting, but rather reflecting on it. It is an unfair characterization of nurses that they become sloppy after becoming licensed. Finally, the means and method by which nursing care is provided are important; the end result is not the sole consideration.

14 - The nurse is applying Tanner's Clinical Judgment Model in the care of a client. Building off the context and background information, place the components of the model in the correct sequence. (4) (nirr)

1) noticing 2) interpreting 3) responding 4) reflecting *Tanner's model represents an interactive process that generally follows the sequence of noticing, interpreting, responding and reflecting (both on-action and in-action).

14 - Tanner's Clinical Judgment Model (CJM) CORE ELEMENTS

1) noticing 2) interpreting 3) responding 4) reflecting This model is a go-to due to the first 3 components supported by reflection pg 385

14 - NCSBN Clinical Judgment Measurement Model (CJMM) - the result or observed outcome of critical thinking and decision making STEPS?

1) recognizing cues 2) analyzing cues 3) prioritizing hypotheses 4) generating solutions 5) taking an action 6) evaluating outcomes

15 - A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply. Redness and blisters forming on both legs Crying and trying to scratch legs due to itching 4-year-old at 85 percentile of growth and development Stating "My legs feel like they are burning" Respirations 18 breath/min and regular

15 - A family presents to the emergency room with a 4-year-old child who is crying and reporting that the skin on the legs are itching and hurting. The parent explains that they were out walking in the woods when the child went running off the path and into some tall weeds. Which finding(s)s should the nurse prioritize in this assessment? Select all that apply. Redness and blisters forming on both legs Crying and trying to scratch legs due to itching

13 - Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)? Grip weakness in the right hand A client report of shooting pain up the left leg Crackles in bilateral lung bases A blood glucose level of 108 mg/dL

A client report of shooting pain up the left leg

13 - Which action exemplifies the purpose of evaluation in the nursing process? Determine the client's health status, self-care ability, and need for nursing. Decide whether to continue, modify, or terminate client care. Develop an individualized plan of client care. Develop a prioritized list of nursing concerns.

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

13 - A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do? (ADPIE) Determine whether the prescribed treatment was effective. Formulate a plan of care based on risk for dehydration. Check the client's skin turgor. Administer an additional liter of intravenous fluids.

Determine whether the prescribed treatment was effective. **The sequence of the nursing process is assessment, diagnosis, planning, implementation, and evaluation. Checking skin turgor is an assessment. Formulating a care plan is part of planning. Administration of additional fluid occurs during implementation. The nurse evaluates whether the intervention was effective, as demonstrated by a rise in blood pressure and a decline in pulse rate.

13 - Which action should the nurse associate with outcome identification and planning in the nursing process? Develops a prioritized list of problem-based nursing concerns. Decides whether to continue, modify, or terminate nursing care. Develops an individualized plan of nursing care. Determines the client's health status, self-care ability, and need for nursing.

Develops an individualized plan of nursing care. **In the process of outcome identification and planning, the nurse adapts the identified nursing concern to address the client's strengths, thereby individualizing the plan of care.ssessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care.

13 - A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment? Do not document this assessment because the client could be using a wireless device to talk to family. Document this assessment based on the client's behaviors. Do not document this assessment because it is subjective. Document that the client is talking back to the voices in the client's head.

Document this assessment based on the client's behaviors.

13 - Which action is performed in the implementation step in the nursing process? Selecting nursing interventions Documenting the plan of care Identifying measurable outcomes Documenting the nursing care and client responses

Documenting the nursing care and client responses **The implementation step in the nursing process involves documenting the nursing care and client responses. Planning involves selecting nursing interventions, documenting the plan of care, and identifying measurable outcomes.

13 - A nurse administers medications to a client. Which step of the nursing process would the nurse perform next? Planning Diagnosing Assessing Evaluating

Evaluating

13 - Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing? Person-centered care Informatics Evidence-based practice Teamwork and collaboration

Evidence-based practice

1) Problem—identifies what is unhealthy about patient 2) Etiology—identifies factors maintaining the unhealthy state 3) Defining characteristics—identify the subjective and objective data that signal the existence of a problem

Formulating a nursing Dx

14 - An experienced nurse has received a new client and will apply the principles of inductive reasoning in the care-planning process. What action will the nurse perform first when applying this form of clinical reasoning? Identify a respected nursing theory to inform care. Hypothesize the client's most likely diagnoses and challenges. Select the principles that relate most closely to the client's admitting diagnosis. Gather objective and subjective assessment data

Gather objective and subjective assessment data **Inductive reasoning requires observing, then drawing conclusions. That is, the process begins with data (such as assessment findings) and then progresses to identification of patterns or explanations. Presupposing the client's challenges or diagnoses would be contrary to this linear process. Beginning with a principle or theory is consistent with deductive reasoning.

13 - Which statements are true about the implementation phase of the nursing process? Select all that apply. Care provided during implementation should be documented in the client's chart. This phase promotes wellness and restores health. All interventions carried out during this phase must be accompanied by a health care provider's order. Implementation is the process of carrying out the plan of care. Implementation is only carried out by nursing professionals.

Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health. Care provided during implementation should be documented in the client's chart.

14 - Define inductive reasoning.

Inductive reasoning - cognitive process in which one identifies a specific idea or action and then makes conclusions about general ideas

14 - The nurse is participating in a client conference for a client who has complex health needs. The client's psychiatrist, occupational therapist, and social worker are also participating in the conference. The nurse is most clearly demonstrating the values of what organization? The Joint Commission National Council of State Boards of Nursing Interprofessional Education Collaborative National League for Nursing

Interprofessional Education Collaborative **Active collaboration between health professions is the cornerstone of the Interprofessional Education Collaborative (IPEC) competencies. The actions are wholly consistent with the values of the other listed organizations, but the interdisciplinary nature of this action is a direct and practical example of IPEC competencies.

14 - A skilled nurse is providing care for a client with mental health needs who is recovering from a stroke. The client is experiencing dysphagia (difficulty swallowing), so the nurse is working together with the speech-language pathologist (SLP) to ensure the client's cooperation with a swallowing assessment. This nurse's action best demonstrates: the American Nurses Association (ANA) Nursing: Scope and Standards of Practice. Rest's model of moral reasoning. reflection-in-action. Interprofessional Education Collaborative (IPEC) core competencies.

Interprofessional Education Collaborative (IPEC) core competencies. *Interprofessional Education Collaborative (IPEC) core competencies emphasize the need for interdisciplinary teamwork and collaboration, as demonstrated by working directly with a member of another health discipline. Reflection-in-action is a form of introspection and analysis within Tanner's model of clinical judgment, but there is no obvious indication that the nurse is doing this. The nurse's action is consistent with Rest's framework but this framework focuses on moral action, which is not described in the scenario. The nurse's action is well within the ANA Scope of Practice, but the focus on collaboration and teamwork is a more clear and apparent function.

13 - Which is a characteristic of person-centered care? It is a framework for providing care. It involves general care for all clients. It can be used in hospital settings. It is independent of other disciplines.

It is a framework for providing care.

13 - Which statement regarding critical thinking in nursing is true? It shows trends and patterns in client status. It is a systematic way of thinking. It makes judgments based on conjecture. It supplies validation for reimbursement.

It is a systematic way of thinking.

14 - NCSBN Clinical Judgment Measurement Model (CJMM)

Layers 0-2 - emphasize how CJ informs the clinical decisions made to address the client's needs P 388

13 - The nurse is caring for a client with an identified nursing concern of fluid volume deficiency. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of fluid volume deficiency. What should the nurse do next? Modify the plan of care and interventions to meet the client's needs. Reassess the client for more symptoms of fluid volume deficiency. Develop an additional nursing concern to meet the client's health needs. Change the nursing concern, because the client's problem was falsely identified.

Modify the plan of care and interventions to meet the client's needs. **The nurse should review the plan of care and its implementation periodically and, as needed based on evaluation, modify them to meet the client's needs. Because this client continues to exhibit symptoms identified by the nursing concern, the implementation should be modified to better meet the client's needs and outcomes. Because the original nursing concern appears to be accurate, there is no indication that it falsely identifies the client's problem or that another one is needed. There is no need to reassess the client for more symptoms of fluid volume deficiency, because it is evident that the client has this problem.

13 - The nurse enters the room of an adult client who reports postoperative abdominal pain. The client states that the pain is severe but is relieved some when getting up to go the bathroom. Which is the nurse's best determination based on this assessment? The client should not be ambulating with pain. The client's pain is really not that bad because the client can ambulate. More assessment would be beneficial to determine whether pain medication is desirable. Even with pain, the client is ambulatory and therefore ready for discharge.

More assessment would be beneficial to determine whether pain medication is desirable. Assessment is the collection of data that enables the nurse to make judgments about the level of care the client needs. More assessment is needed about this client's pain to determine the status and the need for intervention. There is not enough information to determine whether the client is ready for discharge. The health care provider should not question a client's report of pain. Clients may ambulate with pain.

14 - A nursing student is excited to begin the first semester of the program and has learned that the competencies embedded in the program include human flourishing, nursing judgment, professional identity, and spirit of inquiry. What is the source of these competencies? Department of Health and Human Services National League for Nursing Centers for Disease Control and Prevention American Association of Colleges and Universities

National League for Nursing The competencies identified by the National League for Nursing include human flourishing, nursing judgment, professional identity, and spirit of inquiry. None of the other listed organizations share this particular taxonomy of competencies.

13 - A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care? Reflection Experience Clinical reasoning Nursing process

Nursing process

13 - A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process? Evaluation Diagnosis Planning Implementation

Planning During the planning phase, the nurse examines alternatives and judges the worth of evidence using this information to develop the plan of care for the client. During diagnosis, the nurse analyzes the assessment information to identify actual or potential responses to health problems. During implementation, the nurse carries out the plan of care. During evaluation, the nurse determines outcome attainment, revises plans, and identifies a client's perception of results.

13 - The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated? Assessing; diagnosing Planning; implementing Implementing; evaluation Diagnosing; implementing

Planning; implementing

13 - A nurse has developed a plan of care for an adult client. What nursing function is important when using the identified nursing concerns to guide the care of this client? Add a new nursing concern in the nurse's own words to individualize the plan of care. Keep resolved nursing concerns as part of the plan of care in case the related problems return. Do not allow the client to review the nursing concerns identified for them. Prioritize the nursing concerns.

Prioritize the nursing concerns. **After performing a nursing assessment, data should be analyzed and compiled into actual and potential health problems and documented as nursing concerns. It is the nurse's responsibility to prioritize the nursing concerns, thereby prioritizing the care of the client. Resolved nursing concerns should be deleted from the plan of care as soon as they are resolved and replaced with new ones when appropriate. Nursing concerns should be written in a nonjudgmental way and in legally advisable terms, not in the nurse's own words. The plan of care is individualized for each client; therefore, the client should be aware of what is included.

LP 8 - Anxiety related to situational crisis and stress (related factors such as loss of employment) as evidenced by restlessness, insomnia, anguish and anorexia (defining characteristics).

Problem-Focused Diagnosis Example

13 - Which is the best example of person-centered care provided by a registered nurse? Insertion of a nasogastric tube for gastric decompression Administration of pain medication every 4 hours to a client who is postoperative Development of a plan of care for a new admission Reassuring a client who is anxious about a procedure

Reassuring a client who is anxious about a procedure **Person-centered care involves consideration of a client holistically by incorporating an awareness of the client's feelings into the provision of care. Person-centered care is different from task-oriented care in that the task-oriented nurse is only focused on completing tasks in a timely manner. Reassuring a client who is anxious about a procedure shows caring in that the nurse considers the client's feelings about the procedure and does not focus only on the procedure as a task in and of itself. Administering pain medicine, development of the plan of care, and insertion of a nasogastric tube are all important tasks but are not the best example of person-centered care.

14 - An experienced nurse uses cognitive continuum theory (CCT) to inform interactions with clients and families. To optimize the component of intuition in this theoretical framework, the nurse will perform what action? Prioritize feelings over facts to enhance intuition. Participate in interprofessional education whenever possible. Explain the rationale for each nursing action to clients. Reflect carefully to uncover personal biases.

Reflect carefully to uncover personal biases. **The use of intuition requires a close examination of bias, both known and unconscious. Explaining actions to clients and participating in interprofessional education is helpful and respectful, but this act does not necessarily increase the nurse's intuition. Intuition does not consist of prioritizing feelings and downplaying facts; rather, it integrates the two.

13 - The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action? Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. The nurse decides to turn the client every 4 hours because everyone is too busy to help. After turning the client alone, the nurse realizes that the nurse should have insisted on having help. During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help

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

Risk for infection as evidenced by inadequate vaccination and immunosuppression (risk factors).

Risk Diagnosis Example

- There are no related factors (etiological factors), since we are identifying a vulnerability in a patient for a potential problem; the problem is not yet present. Therefore, we identify the risk factors that predispose the individual to a potential problem.

Risk Nursing Dx: They are more likely to develop this problem. Doesn't currently have it, but is at a higher risk than others.

13 - The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis? Risk for falls Hypertension Congestive heart failure Pneumonia

Risk for falls

13 - Which are characteristics of one who has developed critical thinking skills? Resilient, authoritative, reactive, and private Curious, other-directed, fallible, and humble Creative, oriented to success, self-determined, and perfectionistic Self-aware, honest, persistent, and authentic

Self-aware, honest, persistent, and authentic

Purpose of identifying the etiology in a nursing Dx

Suggests the appropriate nursing measures *Fears of falling in the tub & obesity --> as evidence by (AEB)

Purpose of identifying the problem in a nursing Dx

Suggests the pt outcomes (expectations for change)

14 - The public health nurse is performing a postpartum home visit to a first-time parent who describes themselves as "awfully anxious." In alignment with Tanner's model of clinical judgment, the nurse has taken notice of the subjective and objective data that are relevant to the client's state of mind. Before responding by providing interventions, which action will the nurse take? Corroborate the assessment findings with the client. Systematically interpret the meaning of the assessment data. Perform reflection on-action to better prepare for arranging supports for the client. Elicit guidance from an expert nurse in light of the psychosocial nature of the client's challenges

Systematically interpret the meaning of the assessment data. **Within Tanner's model, the stage of "noticing" is followed by "interpreting," in which meaning is assigned to the various cues. Reflection on-action takes place after the clinical encounter in Tanner's model. The model does not explicitly identify the need for expert guidance, and it is not necessary or practical to corroborate each assessment datum with the client.

14 - A nurse has entered a client's home and noticed the client's disheveled state and several fall risks in the home. The nurse has interpreted these data as indications of a need for increased home support for the client and responded by arranging for care. The nurse reflected on the client's response to this suggestion, as well as reflected on the course of this interaction after the fact. The nurse has most clearly exemplified what model? California Critical Thinking Disposition Inventory (CCTDI) Tanner's clinical judgment model Developing Nurses' Thinking (DNT) model The Lasater clinical judgment rubric

Tanner's clinical judgment model **Although the nurse's actions are not inconsistent with any of the listed models, the integration of the specific steps of noticing, interpreting, responding, and reflecting demonstrates Tanner's clinical judgment model.

14 - A nurse has entered a client's home and noticed the client's disheveled state and several fall risks in the home. The nurse has interpreted these data as indications of a need for increased home support for the client and responded by arranging for care. The nurse reflected on the client's response to this suggestion, as well as reflected on the course of this interaction after the fact. The nurse has most clearly exemplified what model? Developing Nurses' Thinking (DNT) model Tanner's clinical judgment model California Critical Thinking Disposition Inventory (CCTDI) The Lasater clinical judgment rubric

Tanner's clinical judgment model **Although the nurse's actions are not inconsistent with any of the listed models, the integration of the specific steps of noticing, interpreting, responding, and reflecting demonstrates Tanner's clinical judgment model.

14 - Which description clearly indicates that the nurse is applying Tanner's Clinical Judgment Model (CJM) in clinical practice? The nurse demonstrates situational awareness by reconciling competing demands according to risk and immediacy. The nurse prioritizes the needs of the client, followed by the family, the support network, and the community. The nurse consistently follows a sequence of assessing, diagnosing, intervening, and evaluating. The nurse engages in a near-constant cycle of noticing, interpreting, and reflecting.

The nurse engages in a near-constant cycle of noticing, interpreting, and reflecting. *Tanner's Clinical Judgment Model (CJM) is a cyclical, iterative process that encompasses the domains of noticing, interpreting, and reflecting. Situational awareness is consistent with the use of a CJM but does not directly suggest the use of this particular CJM. The use of the nursing process is consistent with the CJM, but it is possible to follow the nursing process without applying Tanner's CJM. Similarly, it is possible to prioritize client needs and assign importance to other groups on a stepwise basis without implementing Tanner's CJM.

14 - A novice nurse has been growing in skill, largely as a result of experiential learning in the clinical setting. Within the model of experiential learning, what outcome would most clearly indicate that the nurse has achieved the stage of transformation? The nurse integrates experience and reflections into new forms of practice. The nurse influences the ways that care is organized and provided. The nurse's awareness of ethical and moral issues in nursing becomes heightened. The nurse's actions influence other nurses and nursing students who are less skilled.

The nurse integrates experience and reflections into new forms of practice. *Transformation encompasses meaningful change that results from integrating new experiences with reflections. This may result in practice improvements, increased awareness of ethics, or influence on others, but it is the convergence of experience and reflection that most clearly indicates personal transformation.

14 - In which clinical scenario(s) has the nurse likely applied inductive reasoning? Select all that apply. The nurse integrates the gate-control theory when addressing clients' reports of pain. The nurse has crafted a theory of parental-infant attachment after many years of seeing new parents interact with their infants. The nurse conscientiously applies critical thinking to complex practice situations. The nurse has proposed a model for shift handoff after participating in thousands of handoffs over the years. The nurse applies Erikson's model of growth and development when choosing interventions.

The nurse integrates the gate-control theory when addressing clients' reports of pain. The nurse has proposed a model for shift handoff after participating in thousands of handoffs over the years. **Inductive reasoning requires observing, then drawing conclusions; this is referred to as forward reasoning. Inductive reasoning processes require the ability to recognize patterns and connections and form hypotheses and theories. Applying preexisting theories to particular situations exemplifies deductive reasoning. Critical thinking applies to all nursing actions and interactions and is not limited to situations involving inductive reasoning.

14 - A community health nurse has a reputation that is described as "stellar" by peers and colleagues. Apart from the nurse's years of experience, the nurse's skillfulness is the attribute most described by others. According to cognitive continuum theory (CCT), what characteristic of the nurse suggests that the nurse has achieved the highest level of competence? The nurse is able to apply intuition to complex clinical scenarios. The nurse is highly regarded by peers and colleagues. The nurse has been providing care for over 10 years in the same setting. The nurse readily accepts the most complex client assignments.

The nurse is able to apply intuition to complex clinical scenarios. **Cognitive continuum theory (CCT) acknowledges and integrates both intuitive and analytical cognitive characteristics. These values supersede years of service, reputation, or willingness to take on difficult work.

14 - A novice nurse is being mentored by a more experienced nurse who is able to recognize small but significant client cues and process large amounts of data in a short time. What conclusion(s) should the novice nurse draw about the more experienced nurse's practice? Select all that apply. The nurse has a high capacity for cognitive load. The nurse is able to apply the steps of the Clinical Judgment and Measurement Model (CJMM) simultaneously. The nurse is able to rely on reflection-in-action rather than reflection-on-action. The nurse is able to rely on intuition more than critical thinking. The nurse has well-developed situational awareness.

The nurse is able to rely on intuition more than critical thinking. *Cognitive continuum theory (CCT) acknowledges and integrates both intuitive and analytical cognitive characteristics. These values supersede years of service, reputation, or willingness to take on difficult work.

13 - When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply. Outcome setting allows for individualization of the plan of care. Outcomes can be short- and long-term. All plans of care are the same for clients with certain medical diagnoses. A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. Only the client is involved in outcome setting, not the family.

A plan of care should be comprehensive and ongoing, covering and being updated during all phases of care. Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care.

13 - The nurse is caring for a client with a BMI of 18 and a new diagnosis of food allergy to wheat, rye, and oats. The nurse has identified the nursing concern of altered nutrition that is less than the amount required. What is the most appropriate intervention for this client? Administer a daily multivitamin. Administer a high-calorie diet, excluding wheat, rye, and oats. Monitor for allergies. Weigh client as needed.

Administer a high-calorie diet, excluding wheat, rye, and oats. **Because this client's BMI categorizes them as underweight and they have an allergy to wheat, rye, and oats; administering a high-calorie diet with no wheat, rye, or oats is the most appropriate intervention to meet the specific needs of this client. Administering a multivitamin, monitoring for allergies, and weighing the client as needed are generalized nursing measures and not specific to this client.

14 - A nurse has recommended a regimen of over-the-counter medications for a client who has seasonal allergies. A colleague contends that the nurse has exceeded the scope of nursing practice by recommending medications to a client. To resolve this difference of opinion, the nurses should consult resources from what organization? American Association of Colleges of Nursing National Council of State Boards of Nursing American Nurses Association National League for Nursing

American Nurses Association **While each of the listed organizations provides resources and information of different types, this dispute is directly related to scope of practice, which is delineated by the American Nurses Association's Nursing: Scope and Standards of Practice.

13 - The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? Analyze the data and create an individualized nursing concern for care planning. Identify outcomes for the client with the client's input. Follow up with the client later to determine whether the client's laboratory test results improve. Administer a prescribed medication to decrease the client's blood glucose level.

Analyze the data and create an individualized nursing concern for care planning.

13 - The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client's laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process? Follow up with the client later to determine whether the client's laboratory test results improve. Identify outcomes for the client with the client's input. Analyze the data and create an individualized nursing concern for care planning. Administer a prescribed medication to decrease the client's blood glucose level.

Analyze the data and create an individualized nursing concern for care planning.

13 - The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the next nursing action? Establish a nursing concern of altered skin integrity. Document the rash in the client's chart. Assess the client's back visually. Report the rash to the health care provider.

Assess the client's back visually. **Assessment is the first phase in the nursing process, so the nurse should perform a visual assessment of the client's rash before proceeding to activities that pertain to later phases, such as reporting or documenting the rash or formulating a nursing concern.

13 - A nurse is conducting focused data collection and recognizes the existence of cues. The nurse is most likely involved in which phase of the nursing process? Diagnosis Planning Implementation Assessment

Assessment **During assessment, the nurse recognizes the existence of cues and conducts a focused data collection. During diagnosis, the nurse clusters cues, interprets the clusters, and validates the diagnoses for accuracy. Planning involves preparing a client plan of care, which directs the activities of the nursing staff in the provision of care. Implementation is the action phase of the nursing process.

14 - For which scenario will the nurse consult resources from the American Nurses Association? The nurse is seeking guidance on QSEN competencies. *Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work. The nurse is unsure whether a particular intervention is in the nursing scope of practice. The nurse is unsure how to frame feedback to a preceptor student. The nurse needs to provide updated NCLEX information to a group of students.

The nurse is unsure whether a particular intervention is in the nursing scope of practice. **The American Nurses Association (ANA) produces Nursing: Scope and Standards of Practice. The National Council of State Boards of Nursing (NCSBN) administers the NCLEX. Quality and Safety Education in Nursing (QSEN) competencies are not within the purview of the ANA. Various organizations provide information and guidance on working with students, but this is not specific to the ANA.

14 - A nurse is distraught that she failed to intervene promptly in a situation where a client's status declined sharply. The client was becoming agitated and aggressive. The nurse states, "There was just too much going on, all at once, and I basically froze and then panicked." What interpretation of this event is most accurate? The speed and complexity of the situation overwhelmed the nurse's cognitive load. The nurse failed to understand the importance of clinical judgment and clinical reasoning. The nurse applied inductive reasoning at a time when deductive reasoning would have been preferable. The nurse's situational awareness increased throughout the event.

The speed and complexity of the situation overwhelmed the nurse's cognitive load. *Overstimulation in this case overwhelmed the nurse's cognitive load, leading to a failure to recognize, process, and act upon information. This is unrelated to the differences between inductive and deductive reasoning. The nurse's situational awareness decreased once overwhelmed, not increased. It is unlikely that this nurse's response was related to a lack of understanding that clinical judgment and clinical reasoning are important.

14 - A student nurse has been challenged to apply the principles of critical thinking during laboratory simulations. What characteristic of the student nurse's actions suggests that the student nurse engaged in critical thinking? The student nurse respectfully criticized the actions of student nurses who did not choose the recommended approach. The student nurse thought systematically and reflectively before deciding what to do. The student nurse identified every available option before choosing an action. The student nurse adopted a position of likely being wrong rather than expecting to be right.

The student nurse thought systematically and reflectively before deciding what to do. *Although there are many definitions of what constitutes critical thinking, there is broad agreement that the process involves intentional, reflective thinking to inform an action. This approach does not presume that one will likely be wrong. It often leads to an examination of various options, but it is not realistic to identify every possible option. Critical thinking is not synonymous with criticizing others.

13 - The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use? Critical thinking Scientific problem solving Trial-and-error problem solving Intuitive thinking

Trial-and-error problem solving

13 - The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems? self-perception nutrition activity and rest health promotion

activity and rest **A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertinent for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.

13 - A nurse has completed a client assessment and is preparing to identify appropriate nursing concerns. Which area(s) will the nurse likely address in the nursing concern? Select all that apply. ineffective coping heart failure pneumonia altered mobility altered nutrition

altered mobility altered nutrition ineffective coping

14 - A nursing student is moving through a curriculum that emphasizes the value of experiential learning. The nursing student is consciously linking previous experiences with new and transformative practices. How will the nursing student link experiences with transformative behaviors? by eliciting input from a trusted professional mentor by gaining the widest possible variety of learning experiences by reducing the amount of time elapsed from previous experiences to new experiences by engaging in frequent and thoughtful reflection

by engaging in frequent and thoughtful reflection *In experiential learning, there is a progression from experiences to reflection to transformation. Without reflection, new learning cannot be gleaned from experiences and used to inform future actions. Simply increasing the pace or quantity of learning is not sufficient, nor can a mentor's guidance replace this vital step.

14 - principles of inductive reasoning

cognitive process in which one identifies a specific idea or action and then makes conclusions about general ideas

14 - A nursing student has been providing care for several clients in both community and hospital settings. For which client will the nurse use a concept map when planning and providing care? client who has presented to the clinic for a scheduled immunization client who has just been admitted to the emergency department with shortness of breath community-dwelling client with complex physical and psychosocial needs client who requires discharge teaching related to surgical wound care

community-dwelling client with complex physical and psychosocial needs *Although concept maps can inform care in a wide variety of circumstances, they are especially helpful when planning care for clients who have longstanding, complex needs. Concept maps have less utility in time-dependent circumstances like emergencies or in clients whose needs are more finite, such as clients needing specific teaching or a single immunization.

14 - What action by the nurse in a hospital setting best exemplifies the goals of the Interprofessional Education Collaborative (IPEC) core competencies? reporting a sudden decline in a client's status to the health care provider taking a course about intimate partner violence that was created by a social worker coordinating with the physical therapist to amend a client's activity orders in the plan of care administering a medication that was just prescribed by a health care provider

coordinating with the physical therapist to amend a client's activity orders in the plan of care *Interprofessional Education Collaborative (IPEC) competencies go beyond carrying out orders from another profession, reporting to a member of another profession, or one-way learning from another profession. Active collaboration on client care, such as working together on activity orders, demonstrates the participatory nature of the competencies.

13 - The nurse assesses a client's blood pressure, which is 160/90 mm Hg. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure, finding it to be 140/78 mm Hg. What has the nurse implemented with the second action? appraising planning implementing evaluating

evaluating

14 - The nurse has provided analgesia to a client who was reporting pain, and the nurse used the NCSBN Clinical Judgment Measurement Model (CJMM) to inform the process. What action by the nurse represents the final step in this model? documenting the administration of the analgesia evaluating the client's pain 30 minutes after administering the analgesia reflecting on the decision-making process modifying the nursing care plan to prioritize the client's risk for pain

evaluating the client's pain 30 minutes after administering the analgesia **Evaluating outcomes is the final step in the CJMM. All of the actions listed are appropriate, but evaluation is the most direct indication of this sixth and final step.

14 - The nurse has provided analgesia to a client who was reporting pain, and the nurse used the NCSBN Clinical Judgment Measurement Model (CJMM) to inform the process. What action by the nurse represents the final step in this model? reflecting on the decision-making process modifying the nursing care plan to prioritize the client's risk for pain evaluating the client's pain 30 minutes after administering the analgesia documenting the administration of the analgesia

evaluating the client's pain 30 minutes after administering the analgesia Evaluating outcomes is the final step in the CJMM. All of the actions listed are appropriate, but evaluation is the most direct indication of this sixth and final step.

14 - The nurse is describing a clinical encounter, stating, "I entered the room, gathered assessment data, and then provided the interventions specified in standard operating procedures." The nurse is applying which conceptualization of clinical decision-making? cognitive continuum theory information-processing model humanistic-intuitive approach Rest framework

information-processing model **The rote, linear approach to addressing issues that disregard client complexities is the information-processing model. Each of the other listed models integrates the complex, human realities of nursing practice.

14 - The nurse is describing a clinical encounter, stating, "I entered the room, gathered assessment data, and then provided the interventions specified in standard operating procedures." The nurse is applying which conceptualization of clinical decision-making? information-processing model humanistic-intuitive approach Rest framework cognitive continuum theory

information-processing model *The rote, linear approach to addressing issues that disregard client complexities is the information-processing model. Each of the other listed models integrates the complex, human realities of nursing practice.

13 - The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately states, "This client is getting worse." This is an example of the experienced nurse using: acute observation ability. illogical thinking. an assumption to guide practice. intuitive problem identification.

intuitive problem identification. **Experienced nurses are able to make clinical decisions based on intuition, or an "inner prompting or hunch" that can lead to early and life-saving interventions. Intuitive problem solving is based on a background of experience, knowledge, and skill. Acute observation ability is using skills to determine the extent of the issue using observation. Logical fallacies (illogical thinking) are used to describe faults in logic that result in false conclusions. Assumption a thing that is accepted as true or as certain to happen, without proof.

13 - The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse? implementing the standard plan of care for all clients with diabetes mellitus involving the client with all the steps of the process in care development ensuring the client is informed after decisions are made with care delivery requiring the client to evaluate the plan of care after implementation

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

13 - The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse? involving the client with all the steps of the process in care development ensuring the client is informed after decisions are made with care delivery requiring the client to evaluate the plan of care after implementation implementing the standard plan of care for all clients with diabetes mellitus

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

13 - A client newly diagnosed with diabetes has been sent home after in-depth education regarding the diabetes management plan. Because the client is newly diagnosed, the nurse included in the plan of care a risk for unstable glucose. What is the most appropriate short-term outcome for this nursing diagnosis in the client? The client will: maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). maintain a normal HgbA1C. log all meals in a diary for the next 6 weeks. not exhibit signs and symptoms of hypoglycemia/hyperglycemia.

maintain a blood sugar between 70 mg/dL (3.89 mmol/L) and 110 mg/dL (6.11 mmol/L). **Outcomes can be short- or long-term, and short-term outcomes should describe a single, observable, and measurable behavior. Maintaining a blood sugar between 70 and 110 mg/dL (3.89 and 6.11 mmol/L) is short-term and is a single, observable, measurable outcome. Logging meals for 6 weeks and maintaining a normal HgbA1C are more long-term goals. Not exhibiting signs and symptoms of hypoglycemia/hyperglycemia is not as measurable/observable as monitoring the blood sugar.

14 - The nurse is applying the Clinical Judgment Measurement Model (CJMM) to the care of a client who has been expressing anxiety. The nurse has recognized and analyzed the various cues that the client is exhibiting, has prioritized hypotheses that may explain the client's anxiety, and is now generating possible solutions. In this particular stage of the CJMM, the nurse is demonstrating which component of Rest's framework of moral reasoning? moral judgment/reasoning moral sensitivity moral character moral motivation/focus

moral judgment/reasoning **Moral judgment/reasoning involves consideration of several courses of action to account for the potential impact on those involved. This is tantamount to generating solutions. Moral sensitivity involves awareness of ethics. Moral motivation is the cognitive process of decision-making. Moral character is the actual implementation of a plan.

14 - A nurse is applying Tanner's clinical judgment model in the care of a postpartum client. Which action by the nurse will constitute the first step in this process? prioritizing hypotheses that may explain the client's condition noticing the significant aspects of the client's condition engaging in reflection engaging in reflection establishing trust and rapport with the client

noticing the significant aspects of the client's condition *Tanner's iterative model begins with noticing; this takes place on the basis of the nurse's initial grasp of the situation and precedes hypothesizing. Reflection takes place during and after interactions but after the initial step of noticing. Trust and rapport are key aspects of care but do not represent the initial stage of Tanner's model.

14 - A nurse is applying Tanner's clinical judgment model to the care they provide. What action characterizes the first step in this process? speculating about the likely causes for the client's health challenges clustering data into meaningful groups partnering with the client and with other members of the care team noticing what is significant about the client's status and circumstances

noticing what is significant about the client's status and circumstances *While Tanner's model is cyclical, a common starting point is characterized as "noticing" (i.e., recognizing cues, which may often be subtle). This must precede any subsequent actions such as analyzing or clustering data, or hypothesizing issues and causes. Partnering with the client and the care team is important, but this is not an explicit component of Tanner's model.

13 - A nurse identifies the following: "The client will report a pain rating of 4 or less within 30 to 45 minutes of receiving prescribed analgesic." The nurse has identified: objective data. intervention. outcome. nursing diagnosis.

outcome.

13 - Which is the most appropriate example of the assessment phase of the nursing process? including a nursing concern of acute pain in the client's plan of care palpating a mass in the right lower quadrant of the abdomen evaluating the temperature of a client given medication for a fever documenting the administration of a medication provided for pain

palpating a mass in the right lower quadrant of the abdomen

13 - The nurse is deliberately engaged in a purposeful activity that leads to action, improvement of practice, and better client outcomes. What activity is the nurse likely performing? memorization reflection data collection assessment

reflection **Reflection is defined as a purposeful activity that leads to action, improvement of practice, and better client outcomes. Memorization is strict learning of material for recall. Assessment and data collection involve careful observation and evaluation of a client's health status but without subsequent action, these activities on their own do not lead to the nurse's growth and the client's benefit.

13 - The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain? expressing empathy documenting opioid dependence repositioning the client reassessing the client's pain

repositioning the client **The nursing process focuses on the client's unique problems, setting priorities, developing goals and outcome criteria, and selecting nursing interventions. Repositioning the client is a nursing intervention; it is nonpharmacologic and does not require a prescription from the health care provider and can assist with pain relief. Documenting opioid dependence is inappropriate and not within the nurse's scope of practice. Reassessing and expressing empathy are not considered to be interventions.

13 - What type of intervention is the nurse performing when the nurse observes the spouse of a postoperative client performing the client's dressing change? technical maintenance surveillance supervisory

supervisory The term "supervisory intervention" is applied in the context of overseeing a client's overall care.

14 - A nurse is navigating a busy morning on a hospital unit and is struggling to finish the necessary tasks in the time available. In response, the nurse has assigned morning hygiene tasks for two clients to an unlicensed assistive personnel (UAP). What QSEN competency is this nurse exemplifying? teamwork and collaboration quality improvement evidence-based practice informatics safety client-centered care

teamwork and collaboration **Although this action is consistent with all the QSEN competencies, delegation is a practical example of the competency of collaboration and teamwork in the clinical setting.

13 - Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: uses critical thinking to direct care for the individual client. uses scientific problem solving to meet client problems. employs communication to meet the client's needs. applies intuition and routine care for clients.

uses critical thinking to direct care for the individual client.

13 - Select the best description of how the nurse applies the nursing process in caring for clients. The nurse: uses scientific problem solving to meet client problems. applies intuition and routine care for clients. employs communication to meet the client's needs. uses critical thinking to direct care for the individual client.

uses critical thinking to direct care for the individual client. The nursing process requires blended skills and critical thinking. Critical thinkers think systematically about the nursing process and apply it for the individual client. Communication is important but not sufficient to meet client needs, and scientific problem solving is used in the laboratory setting, not nursing.

13 - What action will allow the nursing student to learn and improve skills while best minimizing risk for clients? advocating for low nurse-client ratios using simulation laboratories obtaining mentorship focusing on stable clients

using simulation laboratories