Funds Chapter 10 PrepU

Cognitively skilled nurses are critical thinkers. What are characteristics of a critical thinker? Select all that apply.

Being open to all points of view resisting "easy answers" to client problems thinking "outside the box"

A nurse is conducting a client interview and gathers information from secondary sources. Which sources might the nurse use? Select all that apply.

Client's children Client's caregiver Client's physician Client's previous admission record

The type of intervention that the nurse performs when he or she observes the spouse of a postoperative client performing the client's dressing change is described as

Supervisory

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

diagnosis

A nurse manager is developing a program for the unit staff to foster critical thinking. Which activity would the nurse manager implement to promote theoretical knowledge?

encouraging staff to read current journal articles

The nurse assesses a client's blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. What action has the nurse implemented?

evaluation

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill?

intellectual

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:

intuitive problem identification.

The novice nurse demonstrates proper understanding of collaborative problems by making which statement?

"A medical diagnosis of heart failure with the possible consequence of fluid in the lungs could lead to the collaborative problem of pulmonary edema."

A nurse is working with a group of staff members to address the needs of a client as they develop the client's interdisciplinary plan of care. Which question if asked by the nurse addresses the standard of breadth when judging the group's thinking?

"Is there another way to look at this situation?"

The nurse is providing education to a group of middle school students regarding cold weather safety. One of the students asks the nurse how cold her body will get when it is cold outside waiting for the school bus. The nurse responds:

"We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time."

A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask?

"What happened?"

At 0730, the nurse notes that the client states that pain is a 7 on a scale of 0 to 10. Based on this assessment, the nurse administers pain medication to the client. At 0800, the nurse evaluated the client and found that pain was a 4 on a scale of 0 to 10. Which example of documentation most clearly communicates the initial morning assessment?

0730: Client reports pain is a 7 on a scale of 0-10, Morphine sulfate 2 mg IV administered.

A nursing student asks his nursing professor how much time is required for studying to be successful in his nursing classes. The nursing professor provides the student with this general rule of studying time

1 hour of class, then 2 hours of studying

When developing a nursing plan of care and associated client outcomes, what should the nurse recognize? Select all that apply.

A plan of care should be comprehensive, including the initial, ongoing, and discharge planning. Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care.

The nurse is teaching about the nursing processes. In which order should the nurse explain the phases to the student nurse?

ADPIE

Which learner enjoys learning that takes place in the clinical setting?

Active experimenters

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 look to for developing a nursing diagnosis based on this client's musculoskeletal health problems?

Activity/rest

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The clients labs reveal an increased HgbA1C, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?

Analyze data and create an individualized nursing diagnosis

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

Assessment

A nurse demonstrates clinical reasoning during which phases of the nursing process? Select all that apply.

Assessment Diagnosis Planning Implementation Evaluation

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. Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health.

The nurse has entered the room of a newly admitted client who immediately reports feeling short of breath. After identifying this as the client's problem, the nurse uses the process of scientific problem solving. Place the steps in the order the nurse would follow.

Collect assessment data. Formulate a hypothesis. Make a plan for action. Perform hypothesis testing. Evaluate.

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

Continue, modify, or terminate client care.

The nursing process provides a framework for the client and nurse to work together. Recording prioritized outcomes in the plan of care ensures which benefit?

Continuity of care can be provided to the client.

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Determine whether the prescribed treatment was effective.

The nurse is admitting a client to the acute care unit with a diagnosis of dehydration. The client's skin turgor is poor and the mucous membranes are pale and dry. What is the rationale for the next phase in the nursing process?

Develop a prioritized list of current and possible health problems.

Which action does the nurse associate with outcome identification and planning in the nursing process?

Develops an individualized plan of nursing care

A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is most likely in which phase of the nursing process?

Diagnosis

A nurse should have critical thinking attitudes to develop critical thinking skills. One attitude the nurse should possess is orderly thinking to do what is best. Which term best suits this attitude description?

Discipline

The nurse is caring for an obese client who needs to be turned every 2 hours. Which nursing action is an example of reflection for action?

During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. After the shift is over, the nurse wonders if all health care providers are using the appropriate resources when turning this client. The next day, the nurse institutes, as part of the client's plan of care, assistance with turning so that the client gets optimal care without injury to the caregivers

When using the nursing process, the nurse notes that there is a great deal of overlapping of the steps, with each step flowing into the next. What is the term for this characteristic of the nursing process?

Dynamic

Place the nursing activities in the order that they would most likely occur when a health care professional uses the nursing process.

Establishing the database Interpreting and analyzing client data Establishing priorities Carrying out the plan of care Measuring how well the client has achieved desired outcomes Modifying the plan of care (if indicated)

The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0 to 10. There is an order for IV pain medication every 4 hours PRN. The nurse administers the prescribed pain medication to the client. What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0 to 10?

Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect.

The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What does the nurse determine this phase will include? Select all that apply

Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client record. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.

A nurse has completed a client assessment and is preparing to identify appropriate nursing diagnoses. Which areas would the nurse likely address in the diagnosis? Select all that apply.

Impaired mobility Imbalanced nutrition Ineffective coping

According to information-processing theory, the reasoning process that proceeds from specific to general is termed

Inductive

A nurse is engaged in the assessment phase of the nursing process. When completing the physical exam, which techniques would the nurse likely use? Select all that apply.

Inspecting Auscultating Percussing Palpating

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

Intuition can be a clinically useful adjunct to logical problem solving

A nurse has been asked to present an orientation program to a group of newly graduated nurses. As part of the program, the nurse plans to reemphasize the need for critical thinking. When describing this concept, which characteristics would the nurse likely include? Select all that apply.

It requires a conscious and deliberate effort. It requires a systematic and logical approach It involves judgments based on evidence.

What type of learning best takes place in the nursing laboratory?

Kinesthetic learning

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and upon evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next?

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

Which statements are true about informatics in nursing practice? Select all that apply.

Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision making.

A nurse is evaluating a client's care. During this phase of the nursing process, which behavior by the nurse indicates critical thinking?

Outcome attainment

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

Palpating a mass in the right lower quadrant of the abdomen

Which students study the best in a group setting?

People-oriented learners

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

Planning

A nurse has developed a plan of care for an adult client. What nursing function is important when using a nursing diagnosis to guide the care of this client?

Prioritize the nursing diagnoses

The registered nurse (RN) is receiving a shift report from another RN about a client admitted for dehydration. In the report, the client has been prescribed IV fluids and an antibiotic. The oncoming RN asks why the antibiotic has been prescribed. This is an example of which consideration involved in the process of critical thinking?

Purpose of thinking

What is the best example of person-centered care provided by a registered nurse?

Reassuring a client who is anxious about a procedure

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next?

Recheck the temperature paying close attention to technique

What is meant by intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new meanings and appreciations?

Reflection

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process

Personal characteristics demonstrate that one has developed critical thinking. Characteristics of critical thinking include:

Self-aware, honest, persistent, and authentic.

The plan of care for a client with diabetes mellitus includes daily assessment of lab values, but the lab values are outside of the recommended range. The nurse collaborates with the health care provider and the client to change medications included in the plan of care. What characteristic of the nursing process does this illustrate?

Systematic

When the nurse assesses the client's blood sugar, what is the term for the type of skill the nurse is using?

Technical

The nurse is caring for a mother and newborn baby couplet. The mother has a nursing diagnosis of insufficient breast milk but wants to continue to breast feed. The client outcome is to increase milk supply and assure that the infant gains weight. The nurse and lactation consultant work with the mother to implement measures to increase the mother's production of breast milk and assure that the infant is getting the nutrition that is required. At the follow-up visit, the mother's milk production has increased and the baby is gaining weight. What is the most appropriate action by the nurse at this time?

Terminate the plan of care because evaluation reveals that the outcome has been met.

The nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying?

The amount and type of drainage suctioned from the nares, and the client's response

The nurse is caring for a pediatric client with respiratory distress. Upon assessment the client has increased respirations and work of breathing (WOB). Breath sounds are adventitious and the client has thick yellow/green drainage coming from the nose. Based on these findings, the nurse determines that this client has an ineffective airway clearance related to copious amounts of thick secretions and proceeds to perform nasopharyngeal suctioning to relieve some of the secretions. If the nurse were documenting the evaluation of this intervention, what would be documented?

The amount and type of drainage suctioned from the nares, and the client's response

Which outcome does the nurse recognize as being the most appropriate for the client with a nursing diagnosis of risk for infection?

The client has a normal temperature and no signs and symptoms of infection.

The nurse is preparing to document the nursing diagnoses for a client. What is the most appropriate outcome for the nursing diagnosis of impaired gas exchange?

The client will maintain a pulse oximeter reading of greater than 94% (0.94 L).

The clinical nurse manager is evaluating a new nurse graduate who has been employed for 3 months. What type of knowledge does the manager evaluate that is required for competent clinical reasoning? Select all that apply.

The nurse is committed to the organization's mission and values. The nurse is able to organize and manage time efficiently. The nurse understands nursing and medical terminology.

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

Trial-and-error problem solving

The Canadian Nurses Association (CNA) has published the standards of care for which the nurse is responsible. The Standards of Practice are:

assessment, diagnosis, outcome identification, planning, implementation, and evaluation.

A nurse is caring for a post-operative client 1 day after a total abdominal hysterectomy. Which nursing intervention demonstrates caring?

assisting the client to sit up in a chair

Which activity is the clearest example of the evaluation step in the nursing process?

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

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:

complete postoperative assessment

An obese client is in the clinic to be started on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for the client? The client will:

create an exercise plan that is realistic and valued

A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. What behaviors is the nurse demonstrating in the care of the client?

critical reflectivity.

The nurse has obtained assessment data from a client and is proceeding to the next phase of the nursing process. What would be the importance of the diagnosing phase of the nursing process?

develop a prioritized list of client-centered problems.

The nurse analyzes client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve. Which step of the nursing process is the nurse performing?

diagnosing

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).

What result is the most appropriate outcome for the nursing diagnosis of Impaired Urinary Elimination? The client will:

maintain urine output of 30 mL/hr.

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:

outcome

The nurse is caring for a newly admitted client. How can a nurse obtain a more complete database for this client?

perform a comprehensive client assessment

The nurse is using the nursing process when caring for the needs of a client. What is the most beneficial use of the nursing process in addressing the needs of the client?

provides a universally applicable framework for nursing activities

In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged?

reevaluating experience in light of ideas

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

Nurses use the nursing process to plan care for clients. In which cases is the nursing process applicable? Select all that apply.

when nurses work with clients who are able to participate in their care when families are clearly supportive and wish to participate in care when clients are totally dependent on the nurse for care when families are not supportive and do not wish to participate in care.