PrepU-- Nursing process

Your patient is admitted with multiple injuries, including a head injury, fractured ribs, and hypoventilation. Vital signs are: BP 110/84, T. 98.8, P. 88, Resp. 28. The nursing care priority is which of the following?

* Maintain an open airway* Explanation: A patent airway is always the priority of nursing care, particularly for patients with a head injury and hypoventilation.

*A nursing student is writing a paper for a class assignment and is integrating critical thinking skills. While reviewing the paper, the student asks himself which question to ensure that the breadth of the subject matter has been covered?*

*"Is there another way to look at the question?"* Explanation: Figuring out another way to look at the question addresses the breadth of the subject matter. Expressing the point in another way reflects clarity. Finding out if the statement is true reflects accuracy. Addressing the implications does not necessarily determine whether the matter has been adequately addressed.

What nursing organization first legitimized the use of the nursing process?

*ANA*

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

*Continuity of care can be provided to the patient.* Explanation: When outcomes are recorded and prioritized, each nurse can quickly determine priorities of care and the patient benefits from continuity of care. The nurse may not pick and choose which priorities to accomplish; the plan does not ensure the patient will reach the goals, and the plan of care is more than the patient's "wants".

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

*Diagnosis* Explanation: During the second phase of the nursing process, nursing diagnosis, the nurse reports or analyzes data to identify and define health problems that independent or physician-prescribed nursing actions can prevent or solve. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care, performing interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments.

*The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process? *

*Diagnosis* Explanation: The diagnosis phase involves the analysis of information and deriving the meaning from the analysis. The planning phase involves preparing a care plan and directing the nursing staff in providing care. The implementation phase involves initiation, evaluation of response to the plan, record of nursing actions, and client response to actions. Outcome identification involves formulating and documenting measurable, realistic, client-focused goals.

A nurse interviews a pregnant teenager and documents her answers on the client record. At the same time, the nurse responds to the client's concerns and makes a referral for counseling and maternity care. This scenario is an example of which of the descriptors of the nursing process?

*Dynamic* Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. No one step in the nursing process is a one-time phenomenon; each step flows into the next step. In some nursing situations, all five stages occur almost simultaneously.

A nurse interviews a pregnant teenager and documents her answers on the client record. At the same time, the nurse responds to the client's concerns and makes a referral for counseling and maternity care. This scenario is an example of which of the descriptors of the nursing process?

*Dynamic* Explanation: Although the nursing process is presented as an orderly progression of steps, in reality there is great interaction and overlapping among the five steps. No one step in the nursing process is a one-time phenomenon; each step flows into the next step. In some nursing situations, all five stages occur almost simultaneously.

A nurse has come on day shift and is assessing the client's intravenous setup. The nurse notes that there is a mini-bag of the client's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patient's medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following?

*Ethical/legal skills*

*A nurse administers medications to a patient as part of the implementation step of the nursing care plan. What step of the nursing process would the nurse perform next?*

*Evaluating* Explanation: The five systematic steps of the nursing process are assessment, diagnosing, planning, implementation, evaluation. Evaluation of patient goals follows implementation of nursing interventions. If interventions were effective, the patient goal has been met. Assessing is the first step in which data is collected. Diagnosing is the second step in which the patient problem, that the nurse is able to treat, is identified. Planning occurs after identification of the nursing diagnoses.

Which phase of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?

*Evaluation*

A home health nurse reviews the nursing care with the client and family and then mutually discusses the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?

*Planning* During the planning step, the nurse identifies expected outcomes of the plan of care. The plan of care should be holistic and individualized, specify desired client goals and related outcomes, and identify the nursing interventions most likely to meet those expected outcomes.

*Which of the following interpersonal skills is essential to the practice of nursing?*

*Promoting the dignity and respect of patients as people* Explanation: Characteristics of interpersonal caring that are essential to the practice of nursing include promoting the dignity and respect of clients as people, the centrality of the caring relationship, and a mutual enrichment of both participants in the nurse-client relationship.

Self-evaluation is a method that nurses use to promote their own development, and to grow in confidence in their nursing roles. This process is referred to as what?

*Reflective practice.* Explanation: Reflective practice is the use of self-evaluation by nurses committed to quality nursing practice. The others may be additional gains but are not descriptive of self-evaluation.

While interviewing a client diagnosed with cirrhosis of the liver, the nurse asks about alcohol consumption. The client is hesitant to give information. What would be most appropriate for the nurse to do to elicit this information from the client?

*Rephrase the question in a more acceptable form.* Explanation: The nurse should rephrase the question in a more acceptable form if the client is hesitant to answer. Avoiding further discussion of the topic is inappropriate because alcoholism is an important factor in liver disease. Requesting that the client answer the question and explaining the importance of the question may not help because it may make the client anxious and block communication.

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which of the following is the best example of establishing a therapeutic nurse-client relationship?

*Respect for the client, and engaging in open communication in getting to know the client.*

Which of the following statements is true of the nursing process?

*Scientific problem solving can occur within the nursing process.* Explanation: Problem solving and the nursing process are not competing or mutually exclusive processes. Rather, both scientific problem solving and trial-and-error may take place within the nursing process. One of the strengths of the nursing process is that it is applicable to all nursing contexts.

After developing the plan of care for a client, the nurse implements that plan. What would the nurse most likely use to implement it?

*Technical skills* During the implementation phase, intellectual, interpersonal, and technical skills are used. Awareness of clinical research and knowledge of care standards are important aspects of the planning and the evaluation phase of the nursing process. Observation is an important requirement in the assessment phase for collecting data

*After developing the plan of care for a client, the nurse implements that plan. What would the nurse most likely use to implement it? *

*Technical skills* Explanation: During the implementation phase, intellectual, interpersonal, and technical skills are used. Awareness of clinical research and knowledge of care standards are important aspects of the planning and the evaluation phase of the nursing process. Observation is an important requirement in the assessment phase for collecting data.

A group of nursing students is reviewing information about assessment and sources of information. The students demonstrate a need for additional review when they identify what as a secondary source?

*The client* Explanation: The client is the primary source of data. Secondary sources of information include family members, significant others, other health care professionals, health records, investigation reports, and literature review.

Members of the staff on a hospital unit are critical of a client's family, who has different cultural beliefs about health and illness. A student assigned to the patient does not agree, based on her care of the client and family. What critical thinking attitude is the student demonstrating?

*Thinking independently*

Nursing is a profession in a rapidly changing health care environment. What is the most important reason for the nurse to develop critical thinking and clinical reasoning?

*To provide quality care with nursing ability and knowledge.*

Your patient has had major abdominal surgery and just returned to the unit from the operating room. Your nursing priority is to:

*complete post-operative assessment.*

A nurse has gathered data through interview, observation, and physical assessment of a client and has formulated diagnostic statements. What would the nurse do during the outcome identification phase?

*formulate client-focused goals* Explanation: During the outcome identification stage, the nurse should formulate client-focused goals that are measurable and realistic. Analyzing assessment information and performing diagnostic validation are completed during the diagnosis phase. Establishing nursing interventions is completed during the planning phase

Use of the nursing process in healthcare allows the nurse to address the needs of the client. The nursing process:

*provides a universally applicable framework for nursing activities.* Explanation: The nursing process can be used with all clients, sick or well, of all ages and in all settings. The nursing process was not developed in 1955 nor designed for use by students in their assignments. Critical pathways target desired outcomes for particular illnesses, procedures, or conditions.

*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* Explanation: Reflection at the higher level includes reevaluating experience in the light of ideas, behavior, feelings, and values. Reflection at the basic level includes recalling the sequence of events, identifying a positive situation, and thinking about relationships involved.

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

*self-aware, honest, persistent, and authentic.* Explanation: The characteristics of critical thinking include: self-aware, genuine/authentic, effective communicator, curious/inquisitive, confident/resilient, honest, creative, proactive, persistent, and improvement oriented.

*A group of student nurses is working on developing various nursing skills and are at various stages of skill acquisition. The instructor determines that which student is at the novice stage? *

*the student who uses rules to guide practice* Explanation: During the novice stage of skill acquisition, the learner uses rules to guide practice. The learner considers more facts and rules during the advanced beginner stage. At the competence stage, the learner feels responsible for outcomes. The learner knows the goal and how to achieve it at the expert stage.

Critical thinking is important in making an effective nursing judgment. Which technique would be most effective for the nursing student to adopt to improve classroom success?

*turn errors into learning opportunities* Explanation: The nurse should turn errors into learning opportunities to improve classroom success. Improving reading and writing skills, building a glossary of new words, and practicing active listening helps to improve the basic skills used in listening, studying, and thinking. Asking for assistance is often beneficial and should not be avoided.

*Cognitively skilled nurses are critical thinkers. What are characteristics of a critical thinker? (Select all that apply.)* a) Thinking "outside the box" b) Resisting "easy answers" to patient problems c) Acting like a "know-it-all" d) Accepting the status quo e) Being open to all points of view f) Thinking based on the opinions of others

• Being open to all points of view • Resisting "easy answers" to patient problems • Thinking "outside the box" Explanation: Being open to all points of view allows for the critical thinker to consider all possibilities when problem-solving. Resisting easy answers provides the critical thinker the opportunity to explore all potential answers when problem-solving, as well as prioritization of the answers. Thinking "outside the box" encourages that the best possible answer to the problem is chosen, rather than relying on the same generic answer that may not work for every situation. Basing thinking on the opinions of others does not foster exploration of new ideas or of critically thinking when problem-solving. Acting like a "know-it-all" prevents the acceptance of new ideas and collaboration. Accepting the status quo does not encourage discourages the principles of critical thinking.