The Nursing Process and Critical Thinking

30. A nurse who exhibits an open minded, professionally curious, mature, and self-confident approach to care would be considered a(n) _____.

ANS: critical thinker Curiosity, systematic, analytic, open minded, self-confident, mature, and truth seeking are characteristics of a critical thinker. DIF: Cognitive Level: Comprehension REF: p. 163 OBJ: 5 TOP: Critical Thinking KEY: Nursing Process Step: N/A

29. Examine this goal statement: Patient will walk in the hall unassisted. The two missing components for a correctly stated goal in this example are the descriptors for _____ and _____.

ANS: frequency; time duration time duration, frequency The example lacks the criteria of frequency and time duration. DIF: Cognitive Level: Application REF: p. 160 OBJ: 1 TOP: Goal Statements KEY: Nursing Process Step: N/A

28. In PIE documentation, a type of POMR, the acronym PIE stands for _____, _____, and _____.

ANS: problem; intervention; evaluation problem;evaluation; intervention intervention; evaluation; problem intervention; problem; evaluation evaluation; problem; intervention evaluation; intervention; problem The acronym PIE stands for problem, intervention, and evaluation. DIF: Cognitive Level: Comprehension REF: p. 162-163 OBJ: 3 TOP: PIE Documentation KEY: Nursing Process Step: N/A

11. What is a priority nursing action when a postsurgical patient complains of shortness of breath? a. Raise the head of the bed to 30 degrees. b. Take vital signs. c. Perform a focused assessment. d. Inform the charge nurse.

ANS: A Although all these options will be eventually performed, the initial implementation should be to raise the head of the bed to ease breathing, perform a focused assessment with vital signs and oxygen concentration, and then inform the charge nurse about the patient's symptoms and your assessment findings. DIF: Cognitive Level: Application REF: p. 152 OBJ: 4 TOP: Assessment KEY: Nursing Process Step: Assessment

20. What are standardized care plans considered? a. Clinical pathways b. Evaluation tools c. Outcome criteria d. Nursing intervention based

ANS: A Clinical pathways are standard care plans developed to set daily care priorities, schedule achievement outcomes, and reduce length of hospital stay. DIF: Cognitive Level: Comprehension REF: p. 160 OBJ: 1 TOP: Clinical Pathways KEY: Nursing Process Step: N/A

24. What elements are included in the characteristics of critical thinking? a. Interpretation, analysis, and evaluation b. Patient-centered criteria and problem solving c. Realistic outcomes and frequent evaluation d. Data gathering and assessment

ANS: A Critical thinking is reflective, and reasonable thinking is focused on deciding what to do. Characteristics include interpretation, analysis, evaluation, inference, explanation, and self-regulation. DIF: Cognitive Level: Comprehension REF: p. 163 OBJ: 5 TOP: Critical Thinking KEY: Nursing Process Step: N/A

14. Which is the best example of a nursing order? a. Perform deep breathing exercises twice daily at 1000 and 1400. b. Administer Tylenol every 4 hours as needed for headache. c. Assess skin integrity and risk for impairment. d. Patient will frequently perform quadriceps-setting exercises.

ANS: A Nursing orders should include a specific description of what, where, when, how much, how long, and how the order should be carried out. DIF: Cognitive Level: Application REF: p. 160 OBJ: 1 TOP: Nursing Orders KEY: Nursing Process Step: N/A

10. Which documentation entry reflects objective data? a. An area of erythema is noted on the upper right extremity, measuring approximately 1 4 inches. b. The patient complains of pain in the right left quadrant (RLQ) of the abdomen and rates it 5 on a pain scale of 1 to 10. c. The family states that the patient does not sleep at night and wanders around the house. d. The medical history reveals a history of drug abuse.

ANS: A Objective data are data that are observable and measurable. DIF: Cognitive Level: Application REF: p. 152 OBJ: 3 TOP: Data Collection KEY: Nursing Process Step: Assessment

6. What is the purpose of palpation? a. Determining areas of tenderness b. Differentiating between fluid- and air-filled organs c. Hearing sounds produced by the body d. Systematically approaching a physical assessment

ANS: A Palpation is a method of touching the patient to obtain information about symptoms and signs such as skin temperature, condition, and pain. DIF: Cognitive Level: Knowledge REF: p. 155 OBJ: 2 TOP: Palpation KEY: Nursing Process Step: Assessment

7. A patient complains of a headache. What type of data is this information considered? a. Subjective b. Objective c. Pain assessment d. Undifferentiated

ANS: A Subjective data are reported by the patient or family and cannot be observed. DIF: Cognitive Level: Comprehension REF: p. 152 OBJ: 3 TOP: Subjective Data KEY: Nursing Process Step: N/A

5. What is the most accurate statement about the patient plan of care? a. It is continually reviewed and evaluated. b. It must be reviewed by the primary caregiver. c. It remains in effect until the patient is discharged. d. It can only be changed by the initiating nurse.

ANS: A The care plan should reflect the current needs of the patient. DIF: Cognitive Level: Knowledge REF: p. 151 | p. 159 OBJ: 1 | 2 TOP: Nursing Care Plan KEY: Nursing Process Step: N/A

25. Why is critical thinking an integral part of the nursing process? a. It promotes flexibility and individualized care. b. It incorporates decision making. c. It includes the patient in part of the nursing process. d. It provides guidelines of care.

ANS: A The nursing process is a sequence of steps that requires critical thinking to provide sound, individualized patient care. Critical thinking makes the nursing process accurate, scientifically sound, appropriate, flexible, and individualized. DIF: Cognitive Level: Comprehension REF: p. 163 OBJ: 4 TOP: Critical Thinking and the Nursing Process KEY: Nursing Process Step: N/A

2. What is the correct order of the five steps of the nursing process? a. Data collection, nursing diagnosis, planning, intervention, and evaluation b. Assessment, planning, documentation, intervention, and evaluation c. Data collection, diagnosis, assessment, planning, and evaluation d. History, physical, diagnosis, intervention, and evaluation

ANS: A The nursing process is a systematic method of providing care to patients. Each phase is dependent on the other phases. DIF: Cognitive Level: Knowledge REF: p. 151 OBJ: 1 TOP: The Nursing Process KEY: Nursing Process Step: N/A

26. What actions should a nurse implement when auscultating a patient's chest? (Select all that apply.) a. Use the diaphragm for assessing breath sounds. b. Use the bell for assessing murmurs. c. Apply earpieces pointing toward the ears. d. Wet the chest hair with a cloth. e. Press the diaphragm very firmly against the chest wall.

ANS: A, B, D A diaphragm is used to hear high-pitched sounds, and a bell is used to hear low-pitched sounds. Chest hair is moistened to diminish cracking sounds that could be misleading. The earpieces should be pointing toward the nose. The use of the diaphragm requires light pressure. DIF: Cognitive Level: Application REF: p. 155 OBJ: 2 TOP: Auscultation KEY: Nursing Process Step: N/A

27. In what ways does evidence-based practice support effective nursing care? (Select all that apply.) a. Research on nursing care topics b. Directives from the boards of nursing c. Summation of studies d. Recommendations for nursing care e. Funding research

ANS: A, C, D Evidence-based practice uses current information from independent nursing research entities that has been summarized and formed into recommendations for nursing practice. DIF: Cognitive Level: Knowledge REF: p. 163 OBJ: 6 TOP: Evidence-Based Practice KEY: Nursing Process Step: N/A

4. Who is responsible for initiating the nursing care plan? a. Primary care provider b. Registered nurse (RN) c. Licensed practical/vocational nurse (LPN/LVN) d. Nurse manager

ANS: B The LPN/LVN may contribute to the nursing care plan, but the care plan itself must be initiated by an RN. DIF: Cognitive Level: Knowledge REF: p. 152 OBJ: 2 TOP: Initiation of the Nursing Care Plan KEY: Nursing Process Step: N/A

3. What is the basis of the nursing process? a. Medical diagnosis of the patient b. Identified physiologic and psychologic needs of the patient c. Standards of nursing care provided by the American Nurses Association d. Orders of the primary care provider

ANS: B The nursing process assesses the needs of the patient to establish goals and to carry out nursing implementations. DIF: Cognitive Level: Knowledge REF: p. 151 | p. 159-160 OBJ: 1 TOP: The Nursing Process KEY: Nursing Process Step: N/A

8. A nurse notes the previous 24-hour urine output was 950 mL, well below the normal of 1500 mL. What is an effective nursing order to remedy the impending dehydration? a. Offer more fluids daily. b. Offer 8 oz of juice or water at 0800 (8 AM), 1200 (12 noon), 1600 (4 PM), and 2000 (8 PM). c. Request extra fluid on a diet tray from the kitchen. d. Place a large water pitcher at the bedside during each shift.

ANS: B The statement is clear and measurable and relates directly to the potential of dehydration. The other options are vague and have no measurement criteria. DIF: Cognitive Level: Application REF: p. 160 OBJ: 2 TOP: Nursing Implementation KEY: Nursing Process Step: Implementation

12. Which is an example of a complete nursing diagnosis? a. Peripheral neurovascular dysfunction b. Peripheral neurovascular dysfunction exhibited by patient complaint c. Peripheral neurovascular dysfunction related to decreased sensation, exhibited by the statement "My feet are tingling" d. Peripheral neurovascular dysfunction exhibited by patient statement

ANS: C A complete nursing diagnosis includes diagnosis, related to and exhibited by problem, cause, and signs and symptoms (PES). DIF: Cognitive Level: Application REF: p. 157-159 OBJ: 1 TOP: Nursing Diagnosis KEY: Nursing Process Step: N/A

21. What should documentation include? a. Objective and subjective data b. Observations made by other nursing staff c. Information that is accurate and complete d. Incidence reports

ANS: C Documentation should be clear, concise, complete, and accurate. DIF: Cognitive Level: Comprehension REF: p. 161 OBJ: 3 TOP: Documentation KEY: Nursing Process Step: N/A

15. Which statement best describes Nursing Interventions Classifications (NIC)? a. They are mandated by the North American Nursing Diagnosis Association International (NANDA-I) as interventions that are to be used for all patients. b. They are currently approved nursing goals. c. They are instituted on the basis of individual patient needs. d. They are guidelines for goal setting and documentation of nursing care given to patients.

ANS: C NIC is a standardized list of nursing implementations divided into seven domains. The nurse selects those that pertain to the patient and then implements them. DIF: Cognitive Level: Knowledge REF: p. 160 OBJ: 1 TOP: Nursing Interventions KEY: Nursing Process Step: N/A

23. What is true regarding problem-oriented medical records (POMRs)? a. The focus is on patient response to treatment. b. They are considered source-oriented charting. c. They reflect the patient's current problems. d. They focus on medical diagnosis.

ANS: C POMR is a method of keeping records that focuses on patient problems rather than on the medical diagnosis. POMRs are an excellent form of communication among various disciplines that are providing care. DIF: Cognitive Level: Comprehension REF: p. 161 OBJ: 3 TOP: POMR KEY: Nursing Process Step: N/A

16. A nurse is aware that a patient goal states, "The patient will eat at least 50% of all meals." The nurse has observed the patient eating more than 50% of all meals for 2 days. What is the most accurate evaluation statement? a. Ate well for all meals. b. Problem is resolved; goal is met. c. Goal is met; patient ate 50% of all meals on 7/12 and 7/13. d. Ate 50% of meals.

ANS: C The evaluation statement should reflect the actual outcome compared with the expected outcome, with the qualifying statement of goal met, goal not met, or goal partially met. DIF: Cognitive Level: Application REF: p. 160 OBJ: 3 TOP: Nursing Diagnosis: Evaluation KEY: Nursing Process Step: Evaluation

9. What sound should a nurse anticipate when percussing a patient's abdomen? a. Flat b. Dull c. Tympanic d. Resonant

ANS: C Tympanic notes are anticipated over an air-filled organ such as the stomach. DIF: Cognitive Level: Comprehension REF: p. 155-156 OBJ: 1 TOP: Percussion KEY: Nursing Process Step: Assessment

17. What elements should be included in data collection? a. Information supplied by patient and family b. Health history, physical assessment, and documentation c. Health history and physical assessment d. Assessment, patient records, and diagnostic tests

ANS: D Diagnostic tests supply general information that can be helpful in identifying general areas in which a patient might have a health care problem. Patient records provide valuable information regarding the medical history and present illness. Physical assessment can provide information concerning the patient's current needs. DIF: Cognitive Level: Comprehension REF: p. 152 OBJ: 3 TOP: Data Collection KEY: Nursing Process Step: N/A

22. Which is the most accurate example of documentation? a. 7/27/14; 0945; pt. vomited; pt. looked better after episode—A. Nurse, LPN b. 7/27/14; 0945; pt. vomited large amount; reduced nausea c. 7/27/14; 0945; pt. reported less nausea after vomiting—A. Nurse, LPN d. 7/27/14; 045; pt. vomited 200 ml of partially digested food; pt. states nausea has diminished—A. Nurse, LPN

ANS: D Documentation should be completed immediately after care is given, never before care. It should be timed and dated, ending with the signature of the nurse performing the care or making the observation. Charting should be objective and describe only what is seen, heard, felt, or smelled. DIF: Cognitive Level: Application REF: p. 161-163 OBJ: 3 TOP: Documentation KEY: Nursing Process Step: N/A

18. When reviewing a patient care plan the nurse reads that "the patient will maintain an adequate nutritional state without nausea or vomiting." What does this statement represent? a. Intervention b. Process c. Diagnosis d. Goal

ANS: D Goals should be stated in terms of observable patient outcomes. DIF: Cognitive Level: Comprehension REF: p. 160 OBJ: 1 TOP: Nursing Goals KEY: Nursing Process Step: N/A

19. What is the Nursing Outcomes Classification (NOC) a method of classifying? a. Nursing process b. Nursing care plan c. Nursing goal d. Nursing intervention outcome

ANS: D The NOC is a new classification system for outcomes that are amenable to nursing implementations. DIF: Cognitive Level: Knowledge REF: p. 160 OBJ: 1 TOP: Nursing Outcomes Classification KEY: Nursing Process Step: N/A

1. What is the primary purpose of incorporating the nursing process into the care of patients? a. Establish a basis of communication with other nursing staff members. b. Maintain compliance with existing national nursing standards. c. Provide structure and organization to the delivery of medical care to the patient. d. Address current health issues, as well as health maintenance and rehabilitation.

ANS: D The goal of the nursing process is to alleviate, minimize, or prevent actual or potential health problems and direct nursing care, not medical care. DIF: Cognitive Level: Knowledge REF: p. 151 OBJ: 1 TOP: Purpose of the Nursing Process KEY: Nursing Process Step: N/A

13. A nurse assisting with prioritizing nursing diagnoses should select which nursing diagnosis as the highest priority? a. Impaired adjustment b. Acute pain c. Risk for imbalanced body temperature d. Ineffective airway clearance

ANS: D Without a clear airway, no need exists for the other diagnoses. DIF: Cognitive Level: Application REF: p. 157-159 OBJ: 7 TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning