302 CH 15 and 16

Which action will the nurse take during bedside hand-off at shift change?

Share information about the patient's condition.

Which assessment question will the nurse ask to obtain data regarding the patient' s cognitive-perceptual pattern when conducting the initial assessment of an elderly patient admitted to the hospital with diabetes mellitus?

"Who is the current president?" "What is the date?" "What is the year?

Which critical thinking skill has the nurse applied when concluding that a patient has a surgcal site infection based on the patient' s incisional pain, fever, and nausea?

Analysis

In an acute setting, which decision criterion does the nurse use to prioritize patient problems?

Clinical condition of the patients Maslow's hierachy of needs Time and staff resources available for delegation Patients' expectations of care Risks involved in treatment delays

To perform comprehensive care planning, which strategy woud the nurse use to gather data from a patient with genital lesions and a history of multiple sexual partners?

Create a concept map. Use fairness. Ask objective questions

Which pattern will the nurse not include as a functional pattern in Gordon ' s model?

Dependence-independence pattern

Which critical thinking attitude is the nurse exhibiting when providing thorough and appropriate care to a patient who has had repeated hospitalizations for diabetes management and a long history of noncompliance with insulin administration and dietary recommendations?

Fairness Integrity Discipline

Which nursing action is needed for a 50-year-old male patient who is 2 days post-surgery for a gallbladder removal, reporting pain and oozing noted from the surgical site?

Gather information about the problem, identify the exact problem, plan appropriate nursing action, perform the required nursing actions, and then evaluate the outcome.

Arrange the steps of the scientific method in the correct sequence.

Identify the problem Collect data Formulate a question or hypothesis Test the question or hypothesis Evaluate the results of the study

Which characteristic is a component of critical thinking?

Open-mindedness, continual inquiry, and perseverance Recognition of an issue, analysis of related information, and formation of conclusions Imagination and exploration of alternatives, consideration of ethical principles, and informed decision making

Which nursing assessment will be best for the nurse to use to confirm a lung problem when a patient reports coughing up mucus during the review of systems of the nursing history?

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

Which action will the nurse take when the patient' s caregiver asks to view the patient' s medical records?

Politely tell the caregiver that disclosing the medical records to others is not in accordance with the law.

When providing patient care, which trait is an obstacle to the nurse ' s use of critical thinking?

Prejudice

Which assessment finding will the nurse document as the precipitating factor in a patient with arthritis whose knee pain is worse during rest and climbing stairs but improves when the patient is walking and with ibuprofen and acetaminophen for pain relief?

Rest Climbing up the stairs

Which critical thinking attitude is being applied when the nurse questions a prescription for phenytoin (which is teratogenic) when it is prescribed for a pregnant patient with epilepsy?

Risk taking

According to Facione, which quality of critical thinking does the nurse possess when the nurse states, "I will maintain a sterile field better the next time if I place my equipment in a different location "?

Self-regulation

Which advice would the nursing team leader give to a new graduate nurse who experiences difficulty addressing the needs of the patients?

Spend adequate time gathering data during assessment. Observe the patient's behavior and measure physical findings. On an ongoing basis, evaluate the results of the patient's tests, studies, or treatments.

The nurse observes a student nurse and identifies that which action by the student reflects effective problem solving?

Suggesting possible solutions

Which stage of the interview consists of the nurse saying, "I have just two more questions for you" when assessing a patient with complaints of chest pain?

Terminating the interview

Which is an example of data validation?

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

Which will be a potential source for the nurse to obtain patient information on a 65-year-old male admitted to the hospital with severe abdominal pain?

The patient himself The patient's family members The patient's previous medical records and data

Which interpretation will the nurse make when a 65-year-old patient scheduled for a cholecystectomy asks a number of questions, is restless, and has poor eye contact when speaking?

The patient is anxious.

After receiving the shift report and reviewing the patient care assignment, which criterion does the nurse use for prioritization?

The risks involved in patient treatment delays

To apply critical thinking, how would the nurse respond when a patient asks the nurse, "Why do I have a rash on my hand? It happened soon after I took penicillin for an infection "?

Use knowledge from previous experiences.

Which recommendation would the nurse give to a student nurse who asks for advice about how to become a successful critical thinker?

Use known practice-based criteria for the assessment. Be open-minded about different interventions. Find solutions outside the standard routines of care while still following standards of practice. Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patients. Imagine what it is like to be in the patient's situation

Which critical thinking attitude is the nurse demonstrating when the nurse speaks with both parents of a child who reports that the parents drink alcohol every day and usually abuse the child after the drinking session?

fairness

Which interview technique is the nurse using when asking "What else is bothering you?" when collecting the history of a patient who reports shortness of air?

probing

Which action by the nurse reflects integrity?

Admitting one's own mistakes

Which attitude of critical thinking would the student nurse adopt when beginning an intervention for a patient with severe pain in the lower abdomen?

Confidence

Which type of question is used when starting the assessment of a patient?

Open-ended

During a shift change, the nurse reports to the incoming nurse: "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" Which conclusion can be drawn about the nurse ' s statement?

Stereotyping has influenced the assessment.

To develop confidence in a student nurse, which advice will the nurse give to the student who reports being nervous about caring for a patient with schizophrenia for the first time?

Suggest that the student discuss concerns with a nursing instructor.

Which behavior indicates the nurse's understanding of integrity?

Trying to follow the highest standards of practice Questioning one's own knowledge and beliefs Being honest about and willing to accept own mistakes or inadequacies

Which action by the nurse is an example of the skill of self-regulation in clinical practice?

While caring for a patient, choosing an alternative way to manage a situation based on experience to achieve better outcomes

Which question related to the complaint of pain will the nurse ask when caring for a 50-year-old patient who had his gall bladder removed two days previously and is complaining of discomfort and pain, with some oozing noted from the site of surgery?

"Can you show me where exactly the pain is?" "Have you turned or moved since last night?" "On a scale of 0 to 10, how severe would you rate this pain?

Which question will the nurse ask to gather data about the present illness and health concerns for a patient admitted to the hospital with complaints of abdominal pain?

"Can you tell me about your illness?" "When did the pain start and how long has it lasted?" "Can you show me where the pain is located?" "Is the pain accompanied by any other problems or complaints?"

Which statement is an appropriate open-ended question for the nurse to ask while assessing a 65-year-old male patient with severe abdominal pain admitted to the hospital?

"Describe the nature of your pain." "What do you do to relieve this pain?" "Tell me what makes the pain worse."

Which close-ended question will the nurse use when conducting an interview with a patient?

"Do you have pain now?" "Are you experiencing cramping?" "Do you think the medication is helping you?"

Which question asked by the nurse while interviewing a patient presenting to the emergency department with a headache of 5 days' duration is an example of a closed-ended question?

"Do you have pain now?" "Is your headache severe?" "Are you frightened that the diagnosis will be cancer?"

Which back-channeling technique will the nurse use during the patient interview when assessing a patient in the emergency department reporting fatigue and memory loss?

"I see." "Go on." "All right." Maintain good eye contact, and show interest in what the patient is saying.

Which response by the nurse is an example of probing when assessing a patient who states, "I' ve been sick to my stomach for 3 days " and reports vomiting twice the day before?

"Is anything else bothering you?"

Place the statements from a patient-centered interview in the correct order.

"My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." "Tell me what brought you to the hospital." "You say you've lost weight. Tell me how much weight you have lost in the last month." "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor, correct?" "I have no further questions. Thank you for your patience."

Which statement would the nurse include when providing information about the critical thinking skill of self-regulation to a student nurse?

"Reflect on your experiences." "Be responsible for connecting your actions with outcomes." "Identify ways to improve your performance."

Which question will the nurse ask to strengthen the connection with a postoperative patient?

"Tell me, how are you managing your pain at home?"

Which statement made by the nurse illustrates the critical thinking attitude of integrity, as the nurse responds to a patient who states that range-of-motion exercises following a shoulder injury "are a complete waste of time "?

"The exercises are necessary for you to regain function in your shoulder. Let's decide how best to proceed through the exercises."

Which question is appropriate for the nurse to ask first when beginning the interview of a patient who reports a backache?

"What brings you to the hospital today?"

Which response by the nurse is appropriate when the patient scheduled for a prostatectomy expresses worry that he may not be able to have sex after surgery?

"Your surgeon will talk to you about the surgery. Don't be afraid to ask this question.

Which journal entry might best help the nurse reflect and think about a clinical experience in which a young child died after 45 minutes of resuscitation and the child' s parent told the nurse, "You can't make me feel better; you don't know what it's like to lose a child"?

A description of the efforts to restore the child's blood pressure, what interventions were used, and questions about the child's response to the treatments The meaning the experience had for the nurse with respect to understanding how to deal with a patient's death A description of what the nurse said to the parent, the parent's response, and how the nurse might approach the situation differently in the future

Which assessment approach will the nurse utilize when caring for a 75- year-old patient whose wife passed away a month ago who is now admitted to the hospital with symptoms of H1N1 flu, exhibiting shortness of air with increased respiratory rate of 30 breaths per minute ?

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

Which communication technique utilized by the nurse will best obtain the patient' s full story?

Active listening Back-channeling Use of open-ended questions

Which patient information is usually included in the biographical information that may be collected by the admitting office staff?

Age Occupation Marital status Health care insurance status

Which critical thinking skill helps the nurse make appropriate decisions about treatment for a postoperative patient who is experiencing pain?

Analytical Systematic Inquisitive

Which critical thinking concept is being used when the nurse notifies the health care provider about a suspicion of patient sepsis based on assessment findings of shivering, weakness, and a new onset of unclear thinking?

Analyticity Confidence

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

Anticipating when to make choices without others' assistance

Which activity is involved in the assessment phase of the nursing process?

Asking the patient about concerns and problems Inquiring about the patient's current medications Asking about the patient's past and family medical history

Which aspect of patient care is included in the nursing process?

Assessment Nursing diagnosis Implementation

Which communication technique is the nurse using in an attempt to encourage the patient to share more informatoin about health habits and health problems when the nurse says, "I understand; go on " in response to the patient saying he used to consume alcohol. smoke cigarettes, and take drugs?

Back-channeling

Which level of critical thinking is illustrated when the student nurse refers to a policy and procedure manual before checking the blood pressure of a patient?

Basic

According to Kataoka-Yahiro and Saylor's model, which is a level of critical thinking the nurse would use when caring for a patient who is hospitalized with severe pain in the lower abdomen?

Basic Complex Commitment

The nurse is at which level of critical thinking when the nurse reads the institution ' s procedure manual prior to inserting a urinary catheter?

Basic critical thinking

Which activity illustrates the critical thinking skill of interpretation?

Being orderly in data collection Looking for patterns to categorize data Clarifying any doubtful data

Which characteristic will the nurse document as objective data when performing the initial interview for a patient admitted to the hospital?

Body temperature of 104° F (40° C) A raised, red swelling on the back Drainage from wounds on the right hand and the right foot

Covering both the patient's and the patient's family's viewpoints is an example of which intellectual standard?

Broad

According to R.W. Paul, which intellectual standard would the nurse use in practice when performing critical thinking?

Clear Plausible Complete

Which type of interview technique is the nurse demonstrating when asking the questions, "Do you have pain or cramping?" or "Does the pain get worse when you walk?"

Closed-ended questioning Problem-oriented questioning

Which phase of a patient-centered interview is occurring when the nurse asks the patient several questions such as: "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?"?

Collecting the assessment

When providing postoperative care for a patient, which nursing action represents the use of clinical decision making?

Concluding that the patient's wound is infected after noting incisional drainage and an elevated patient temperature Deciding to medicate the patient for pain before changing the incisional dressing

Which attitude is a component of critical thinking?

Confidence Fairness Discipline Curiosity

Which description explains the evaluation tool of reflective journaling?

Consciously thinking through an activity or experience

After interventions to manage postoperative pain in a patient have been unsuccessful, which attitude of critical thinking is used when the nurse looks for different approaches to relieve the patient' s pain?

Creativity

Which critical thinking attitude is helpful for the nurse to possess to identify new solutions to patient-related problems?

Creativity

Which attribute of the nurse will contribute to a proper assessment on a patient admitted to the hospital with hypertension?

Critical thinking attitude Relevant knowledge Prior clinical experience

Which critical thinking skill is being used by the nurse who determines that a patient is experiencing ineffective coping after the patient states, "Since my sister died 2 weeks ago, I can 't sleep, I am tired all of the time, and I have trouble concentrating at work"?

Diagnostic reasoning

Which will help the nurse apply critical thinking skills when providing care in an acute care setting?

Discipline Responsibility Perseverance

Which pattern of Gordon ' s functional health pattern is the nurse assessing when questioning about bowel movements, urine output, and sweating in a patient admitted to the hospital for severe dehydration?

Elimination pattern

Which statement is true about the types of nursing assessments used to collect patient data?

Emergency assessment is performed when the patient's situation is life threatening. Ongoing assessment is performed and continued throughout the patient's health care experience. Focused assessment is done after a patient's general problems have been identified, when a patient has a complaint, or describes a new problem.

Which step of the nursing process is illustrated when the nurse observes the volume in a patient' s surgical drainage collection device to determine if the health care provider should be notified?

Evaluation

After providing education to student nurses about critical thinking skills, the nurse identifies that further teaching is needed when a student provides which example of critical thinking?

Explaining the procedure for administering tube feeding to a second nurse who has floated to the unit to assist with care

Which critical thinking attitude did the nurse demonstrate when the nurse actively listened to a patient who reported staff rudeness and slow response to call lights and then discussed the concerns with the nurse manager?

Fairness

Arrange the different steps of a problem-oriented approach for comprehensive assessment in the appropriate order.

Focus on the patient's present situation. Ask follow-up questions Conduct a physical assessment. Analyze the nature of the patient's problem. Develop a care plan.

Which information will the nurse include in the orientation phase of an interview?

Greet by using the patient's full name. Introduce yourself, and explain your role. Ensure privacy by closing the door of the room or shutting the curtains.

Which action by the nurse indicates the setting-the-stage phase of the patient-centered interview?

Greeting with the patient's full name Ensuring a private area by shutting doors or closing the curtains Explaining to the patient the reason for conducting the interview

A patient states he is not getting relief from shortness of breath when using his inhaler. Which functional health pattern as identified in Gordon ' s model is the nurse assessing when asking the patient to explain the use of the inhaler and what he does when he gets no relief?

Health perception and health management pattern

While assessing a patient presenting to the pulmonary clinic, which functional health pattern in Gordon ' s model will the nurse address when asking, "I see that it has been more than 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also, I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following this plan?"

Health perception and management

Which datum will the nurse document as objective when assessing a patient with gastroenteritis?

Hemoglobin of 11.2 g/dL Elevated white blood cell (WBC) count Axillary temperature of 98.6° F (37° C)

Arrange the steps of the scientific method of critical thinking in the correct order

Identify the problem Collect essential data Formulate questions Request diagnostic tests Evaluate results

Which factor component can restrict the student nurse's ability to move from a basic level to a complex level of critical thinking?

Inexperience Inflexible attitude Weak competencies

Which purpose will the nurse plan to achieve when performing a comprehensive nursing assessment?

Interpret and validate the data collected. Establish a database about the patient's needs and health problems. Collect data with which to plan and evaluate care.

According to Kataoka-Yahiro and Saylor ' s clinical judgment model for nursing, which factor is a component of environment?

Interruptions

Which information about a concept map would the nurse include when providing education to a group of student nurses?

It is a visual presentation of relationships between problems and interventions. It helps to synthesize relevant data about a patient. It helps to form meaningful patterns from diverse patient information.

Which critical thinking component did the nurse use when reviewing literature about loss, grief, and therapeutic communication before meeting with a patient who was scheduled for a bilateral mastectomy?

Knowledge application

Which approach will the advanced practice nurse use during a routine examination when assessing a 65-year-old patient with nerve deafness wearing bilateral hearing aids?

Lean forward when interacting with the patient. Acknowledge the patient's answers by nodding the head.

Using diagnostic reasoning, which parameter would the nurse use to conclude that a patient is experiencing hypoglycemia?

Lightheadedness Weakness Blurred vision

As a critical thinker, which action would the nurse take when a patient informs the night-shift nurse that the day-shift nurse did not administer a prescribed pain medication?

Listen to the patient but also confirm with the day-shift nurse

When a patient presents with vague epigastric pain, which clinical judgment skill would the nurse use to make a conclusion about whether the pain is gastrointestinal or cardiac in nature?

Look at the situation objectively. Be orderly in collecting the patient data. Be open-minded as information is being analyzed. Support the findings and conclusion. Look at the meaning and significance of the findings.

Which assessment activity reflects effective communication skills during a patient-centered interview?

Meet and acknowledge visitors in the patient's room. Sit next to the patient. Ask the patient to summarize the discussion. Ask, "How would you prefer I address you?" Ask for permission to conduct the interview. Say, "Tell me how you want us to help you."

Which patient assessment finding is documented as objective data when the nurse is caring for a 50-year-old patient 2 days postoperatively after a gallbladder removal who appears to be in pain?

Minimal oozing at the incision site Fever of 104° F (40° C)

Which individual is identified by the nurse as the primary source of information when a 26-year-old female is found unconscious by her mother at home and is transported to the hospital by ambulance followed by the mother and her 1-year-old daughter?

Mother

Which datum will the nurse document as subjective when conducting an admission interview on a patient?

Nausea Light-headedness Discomfort in the stomach

Which datum will the nurse document as subjective when assessing a patient with diabetes?

Nausea with duration of 2 hours Tingling sensation in the feet

Which technique will the nurse use to obtain more information from a 65-year-old male patient admitted to the hospital with severe abdominal pain while completing the health history?

Nod head to show agreement. Lean forward when the patient is talking. Maintain good eye contact with the patient.

Which type of assessment is the nurse performing when using a finger to apply light pressure just above the intravenous site and asking the patient if any tenderness is felt after noting inflammation at the site?

Problem focused

Which critical thinking skill was used when the nurse responded to an intravenous (IV) pump that was alarming, checked for air in the tubing, and then flushed the patient' s intermittent lock, which resulted in the IV bag to infuse as prescribed?

Problem solving

Which response by the nurse reflects critical thinking when provided to a patient with nausea and vomiting who asks to take a ginger supplement rather than the antiemetic medication that has been prescribed?

Recognize that multiple solutions exist. Reflect on the nurse's own beliefs about alternative therapies. Examine the evidence-based information related to treatment of nausea and vomiting.

Which evaluation of clinical judgments is being used when nurses meet after an unexpected death of a patient to discuss actions taken during the event and to identify what other treatments should have been performed?

Reflection

Which technique would the student nurse use to develop critical thinking skills and apply theory in practice?

Reflective journaling

Arrange the stages of a patient-centered interview in the appropriate order.

Setting the stage Setting an agenda Collecting nursing history Terminating the interview

Which action indicates the need for further instruction regarding gathering information from an elderly patient?

Sitting straight in the chair while talking with the patient

Which functional health pattern from Gordon ' s model will the nurse address in the assessment of a patient with a pressure ulcer on his left hip?

Sleep-rest pattern Elimination pattern Nutritional-metabolic pattern

Which information will the nurse elicit to help arrive at the probable cause when a patient is reporting severe abdominal pain in the right iliac region?

Some questions about the digestive system

The nurse uses the nursing process to provide medication education for an older patient who is being discharged from the hospital with three new medications. Place the steps of the nursing process in the correct order.

The nurse asks whether the patient is feeling well enough to learn about the new medicines After reviewing the data that has been collected, the nurse makes an educated judgment about the potential patient problems with the medications. The nurse gathers information about the medications and plans the teaching intervention. The nurse takes the printed medication information to the bedside and discusses each medication with the patient. Upon returning to the patient's room, the nurse asks the patient to describe the medicines that will be taken at home

Which action is appropriate when the nurse finds a patient scheduled for an appendectomy is crying and infers this is because of anxiety?

The nurse validates the inference by asking the patient about the crying behavior.

Which would a clinical interview ideally focus on?

The patient

Which component of patient-related datam reported during the initial patient interview is considered biographical data?

The patient's age The patient's gender

Which strategy would the nurse use to test the effectiveness of an experimental patient intervention in an ethical manner?

Use evidence-based criteria for making clinical judgments. Focus on the patient's values and beliefs related to the new intervention. Be self-aware of the nurse's own beliefs, values, and feelings.

Which strategy will the nurse use to interact with a patient who has undergone throat surgery and is unable to speak?

Use message boards to communicate with the patient.

Which statement accurately describes the process of validating data?

Validate the findings with information from the patient's family. Validate with findings from a physical examination. Validate by asking the patient directly. Validate by contacting the patient's previous health care provider.

Which health pattern describes the patient' s spiritual attitude according to Gordon's model?

Value-belief pattern