CHAPTER 11 - CRITICAL THINKING AND THE NURSING PROCESS: FOUNDATIONS OF PRACTICE
A nurse manager is talking with a new nurse. The nurse manager determines that the new nurse is thinking critically based on which statement? - "I'm not sure what to do here?" - "If I give this medication, the client probably will be sleepy." - "I don't know if the client understands." - "If my client gets short of breath, I'm unclear about why."
"If I give this medication, the client probably will be sleepy." p. 196-197 Rationale: Critical thinking requires the nurse to anticipate what will be next; for example, when giving the medication, the client will probably get sleepy. Critical thinking is also promoted by replacing statements such as "I don't know" and "I'm not sure" with statements and actions to seek out the answer. Lacking the knowledge about "why" does not reflect critical thinking. As stated, critical thinking involves trying to find out the answer
Which statement made by the nurse indicates data that would be documented as part of an objective assessment? - "The client's right leg is cold to the touch, from the knee to the foot." - "The client's sister reports that the client has unrelieved pain." - "The client reports eating all of today's breakfast." - "The UAP reports blood in the client's stool."
"The client's right leg is cold to the touch, from the knee to the foot." p. 208 Rationale: Objective data is information that is observable and measurable, such as observing that the client's right leg is cold to the touch. Subjective data is information that the client or someone else reports, such as reporting unrelieved pain, blood in the stool, or eating one's supper.
A nurse is conducting a client interview and gathers information from secondary sources. Which source might the nurse use? Select all that apply. - Client's previous admission record - Client's children - Client - Client's physcian - Client's caregiver
- Client's previous admission record - Client's children - Client's physcian - Client's caregiver p. 191 Rationale: The client is the primary source of information for assessment. Secondary sources include family members, significant others, other health care professionals, health records, and literature review.
What nursing organization first legitimized the use of the nursing process? - American Nurses Association - State Board of Nursing - International Council of Nursing - National League for Nursing
American Nurses Association p. 195 Rationale: Although the term "nursing process" was first used by Lydia Hall in 1955 and nursing theorists delineated specific steps in a process approach to nursing, use of the nursing process was legitimized in 1973, when the American Nurses Association's Congress for Nursing Practice developed Standards of Practice to guide nursing performance.
The nurse is making morning rounds after receiving reports on clients. The nurse takes the opportunity to greet the clients and do an initial observation. The nurse is actually accomplishing which step of the nursing process? - Implementation - Evaluation - Assessment - Planning
Assessment p. 191 Rationale: The nursing process is a systematic method used by the nurse and client. Assessment is the first step to determine the needs for client care
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? - Clarity - Relevance - Accuracy - Precision
Clarity p. 198 Rationale: The nurse's question reflects clarity, or the need for more information. Accuracy would be reflected in questions about the information being true. Precision is reflected by questions asking for more details or specifics. Relevance would be reflected by questions related to how something connects to the issue
The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill? - Ethical/legal skill - Interpersonal skill - Cognitive skill - Technical skill
Cognitive skill p. 192-193 Rationale: The student is demonstrating the use of cognitive skills, which are characterized by identifying scientific rationales for the client's plan of care, selecting nursing interventions that are most likely to yield the desired outcomes, and using critical thinking to solve problems. Technical skills focus on manipulating equipment skillfully to produce a desired outcome. Interpersonal skills are used to establish and maintain a caring relationship. Ethically and legally skilled nurses conduct themselves in a manner consistent with their personal moral code and professional role responsibilities.
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? - Administer an additional liter of intravenous fluids. - Check the client's skin turgor. - Formulate a plan of care based on risk for dehydration. - Determine whether the prescribed treatment was effective
Determine whether the prescribed treatment was effective p. Rationale: 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
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 client'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 3 hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following? - Cognitive skills - Ethical/legal skills - Interpersonal skills - Technical skills
Ethical/legal skills p. 197 Rationale: Reporting problems and unacceptable practices is an aspect of ethical/legal skills. Technical skills enable the safe performance of kinesthetic tasks while interpersonal skills are the manifestations of caring. Cognitive skills encompass knowledge and critical thinking.
Nurse White is working on a rehabilitation floor today. She has obtained a pair of crutches for her client from the physical therapy department. She and her client set a goal of using the crutches twice daily to ambulate down the hall. However, at the end of the day, the client was only able to ambulate one time because the crutches were the incorrect height. The client's inability to ambulate best represents which phase of the nursing process? Plan Evaluation Intervention Diagnosis
Evaluation p. 191 Rationale: This example illustrates several phases of the nursing process. The nurse evaluated that the plan of ambulating twice that day was unsuccessful. The nurse's next step is to revise the plan based on this evaluation
A nursing instructor is describing the nursing model of person-centered care to a class. Which of the following would the instructor include as a characteristic of person-centered care? - It is a framework for providing care. - It can be used in hospital settings. - It is independent of other disciplines. - It involves general care for all clients.
It is a framework for providing care p. 190 Rationale: The model of person-centered care is a framework for providing care. The approach is not independent of other disciplines, but is interdependent with other disciplines such as medicine, physiotherapy, surgery, etc. The model can be used in all settings and is not limited to hospital settings. Person-centered care aims to provide specific care to people based on individual needs
Which of the following is a true statement regarding critical thinking in nursing? - It makes judgment based on conjecture. - It supplies validation for reimbursement. -It shows trends and patterns in client status. - It is a systemic way of thinking.
It is a systemic way of thinking p. 195, box 11-2 Rationale: Critical thinking is a systemic way of thinking that involves purposeful, outcome-directed thinking. Critical thinking makes judgment based on evidence rather than conjecture. Providing a foundation for evaluation and quality improvement, as well as showing trends and patterns in client status, are functions served by documentation
The client 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. Which is the nursing care priority? - Assess fluid and electrolytes. - Maintain an open airway. - Control his pain. - Monitor vital signs and neurological status.
Maintain an open airway p. 198 Rationale: A patent airway is always the priority of nursing care, particularly for clients with a head injury and hypoventilation
Benner (2000) has developed a model of skill acquisition outlining the stages of increasing expertise. The practitioner who uses rules to predominantly guide practice would best be described as which of the following? Proficient Expert Advanced beginner Novice
Novice p. 199 Rationale: The novice must rely on rules and guidelines to guide clinical judgment. The novice does not yet have the clinical expertise to use previous experiences to think outside of the box
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? - Experience - Reflection - Nursing Process - Clinical reasoning
Nursing Process p. 195 Rationale: Although clinical reasoning, reflection, and experience are important components of nursing, the nursing process is recognized as the method of practicing nursing. It is the model on which professional nursing standards are based. Although it sometimes is criticized for not being adaptable to the changing health care environment, the nursing process remains the almost universally accepted method for providing nursing care
Which statement is true of the nursing process? - It is more appropriate in medical-surgical settings than community health care. - Trial-and-error problem solving is incongruent with the nursing process. - Scientific problem solving can occur within the nursing process. - It is a valid alternative to using intuition to respond to nursing situations.
Scientific problem solving can occur within the nursing process. p. 190, including box 11-1 Rationale: 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.
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? - Show respect for the client, and engage in open communication in getting to know the client. - Recognize how the approach affects client care, and describe why you have to do things your way. - Introduce yourself, and then accomplish nursing care activities efficiently to allow the client to rest. - Approach the client as part of the job, and complete nursing care quickly to promote comfort
Show respect for the client, and engage in open communication in getting to know the client. p. 195 Rationale: Respect for the client's dignity, and establishing a caring relationship, is furthered by mutual exchange of communication. Approaching care/client as a job, doing things without client input, and doing things your way and efficiently are not necessarily therapeutic, nor do they initiate communication
The nurse is caring for a client who is suspected of having a kidney infection. Which scenario involves the use of subjective data from the primary source? - The provider orders the nurse to help the client void. - The client tells the nurse that there is a burning sensation when voiding. - The client's spouse reports the client experienced incontinence a few days ago. - The nurse tells the client to attempt to void.
The client tells the nurse that there is a burning sensation when voiding p. 208-209 Rationale: Subjective data consists of information that the client can describe, such as feelings, sensations, or experiences. Examples of subjective data include clients reporting pain or fatigue. Objective data are those that can be measured and observed from others, such as a client being febrile or a client having a broken bone. The primary source is the client. Secondary sources include family members, reports, test results, and other healthcare providers and include telling the client what needs to be done
Which is not true regarding Nurse Practice Acts? - They define the boundaries of the functions of a nurse. - They vary among states. - They describe what medications nurses can prescribe. - They were established to describe legitimate nursing function.
They describe what medications nurses can prescribe p. 417 Rationale: Prescribing and dispensing medications are not legal practices for registered nurses, with the exception of nurses in advance practice roles.
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 client does not agree, based on her care of the client and family. What critical thinking attitude is the student demonstrating? - Demonstrating confidence - Being curious and persevering - Thinking independently - Being creative
Thinking independently p. 196 Rationale: Although all the attitudes listed are components of critical thinking, the student is thinking independently. Nurses who are independent thinkers are careful not to let the status quo or a persuasive individual control their thinking
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 be able to employ the nursing process in client care. - The licensing examination requires nurses to be adept at critical thinking. - Because clients deserve experts who know how to care for them. - To provide quality care with nursing ability and knowledge.
To provide quality care with nursing ability and knowledge p. 196-197 Rationale: The goal of all nursing is to meet the standard of quality care. Clinical reasoning and critical thinking may be applied in all of the answers but the most important goal in health care is to provide quality nursing care to clients
A client is administered an anxiolytic. Which nursing action demonstrates the nurse evaluating the client? - collecting data about the client's history with anxiety - devising a plan for the client to practice anti-anxiety exercises at home - assigning the client a new nursing diagnosis based on the client's controlled anxiety - asking if the client feels less anxious 30 minutes after administering the medicine
asking if the client feels less anxious 30 minutes after administering the medicine p. 246 Rationale: Evaluation allows the nurse to determine whether the client has met the goal. By analyzing the client's response to the anxiolytic, this helps the nurse determine the effectiveness of the nursing care. The other actions demonstrate other parts of the nursing process.
Which scenario represents a nurse demonstrating the critical thinking process? - collaborating with the respiratory therapist and physical therapist to address a complication - using power for more control and freedom over the daily tasks - assessing whether physician help is needed - assessing why a physician encounter form is missing from the record
assessing whether physician help is needed p. 195-196 Rationale: Critical thinking involves consistency, relevancy, and logical thinking. It enables the nurse to make decisions. Therefore, assessing whether physician help is needed is an example of the critical thinking process. The other actions support other nursing soft skills
The nurse is teaching the student nurse about nursing processes. In which order should the nurse explain the phases to the student nurse? - evaluation -implementation - planning - diagnosis - assessment
assessment diagnosis planning implementation evaluation p. 191
Cognitively skilled nurses are critical thinkers. What are characteristics of a critical thinker? Select all that apply. - acting like a "know-it-all" - thinking "outside the box" - accepting the status quo - thinking based on the opinions of others - being open to all points of view - resisting "easy answers" to client problems
being open to all points of view resisting "easy answers" to client problems thinking "outside the box" p. 195-196 Rationale: 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 one's thinking on the opinions of others does not foster exploration of new ideas, nor does it foster critical thinking when problem-solving. Acting like a "know-it-all" prevents the acceptance of new ideas and collaboration. Accepting the status quo discourages the principles of critical thinking.
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. - taking a client's blood pressure on both arms at the beginning of a shift - giving the client a p.r.n. (as needed) dose of captopril (an antihypertensive) in light of this blood pressure reading - recognizing that the client's blood pressure of 172/101 is an abnormal finding
checking the client's blood pressure 30 minutes after administering captopril P. 193 Rationale: Measuring the client's blood pressure after performing an intervention such as drug administration determines the extent to which the client has achieved the outcome desired, which in this case is lowered blood pressure. Initially checking the client's blood pressure is an example of assessment, while recognizing it as an anomaly constitutes diagnosis. Administering the drug is a form of implementation
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. - administer pain medication. - expect him to be drowsy, and let him rest. - evaluate the abdominal dressing for drainage
complete postoperative assessment p. 191 Rationale: Assessment is the first priority, which would include breathing, level of consciousness (LOC), vital signs, dressing check, IVs, and pain level. After assessing, pain medication may be needed. The nurse may expect him to be drowsy but ongoing assessment is required
A client presents to the emergency room reporting weight gain, respiratory crackles, productive cough, and shortness of breath. The nurse demonstrates the implementation phase of the nursing process by performing which action? - asking the client about family history of respiratory conditions - asking the client what the treatment goals should be - inserting a peripheral IV and urinary catheter - evaluating whether or not the client will need to be admitted
inserting a peripheral IV and urinary catheter p. 241-243 Rationale: Implementation is a measure that the client and nurse use to accomplish outcome criteria. The action of inserting a peripheral IV and urinary catheter is an example of implementing a specific treatment measure. The other actions demonstrate other phases of the nursing process
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: - nursing diagnosis. - outcome. - subjective data. - intervention.
outcome p. 192-193 Rationale: This statement is an outcome statement that focuses on the client, is realistic, and is measurable. Subjective data would include information from the client, such as complaints or reports of anxiety. Nursing diagnosis is a clinical judgment about an individual, family, or community experience/response to an actual or potential health problem. Intervention would be the action to be completed based on the nursing diagnosis and intended outcome (e.g., administering a prescribed analgesic).
Use of the nursing process in health care allows the nurse to address the needs of the client. The nursing process: - is a method of nursing established in 1955. - was developed for use by students in nursing assignments. - targets desired outcomes for particular illnesses, procedures, or conditions. - provides a universally applicable framework for nursing activities
provides a universally applicable framework for nursing activities p. 190, including box 11-1 Rationale: 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
The nurse is consulting with the client. The nurse effectively uses outcome identification by performing which action? - collecting more data - providing the appropriate interventions for the client - discussing what the client expects from the hospitalization - evaluating the client during the consultation
providing the appropriate interventions for the client p. 229-230 Rationale: Outcome identification is the process of defining goals that are individualized to the client. Therefore, providing the appropriate interventions for the client is an example of outcome identification. The other actions do not support outcome identification. They support assessment, evaluation, and planning
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: - assessment of oneself. - learning from mistakes. - promoting the nurse's self-esteem. - reflective practice.
reflective practice p. 198-199 Rationale: 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
Personal characteristics demonstrate that one has developed critical thinking. Characteristics of critical thinking include: - resilient, authoritative, reactive, and private. - curious, other-directed, fallible, and humble. - self-aware, honest, persistent, and authentic. - creative, oriented to success, self-determination, and perfection.
self-aware, honest, persistent, and authentic p. 195-197 Rationale: 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 considers more facts and rules - the student who knows how to achieve the goal - the student who feels responsible for outcomes - the student who uses rules to guide practice
the student who uses rules to guide practice p. 199 Rationale: 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.
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. - applies intuition and routine care for clients. - employs communication to meet the client's needs. - uses scientific problem solving to meet client problems.
uses critical thinking to direct care for the individual client p. 197 Rationale: 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
