Chapter 13: Blended Competencies, Clinical Reasoning and Processes of Person-Centered Care

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 evaluates the client and finds that pain is 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.

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 and ongoing, covering and being updated during all phases of care. Outcomes can be short- and long-term. Outcome setting allows for individualization of the plan of care.

The nurse is caring for an underweight client diagnosed with a new food allergy to wheat, rye, and oats and with a nursing diagnosis of Imbalanced Nutrition: less than body requirements. What is the most appropriate intervention for this client?

Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats

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

Analyze the data and create an individualized nursing diagnosis.

A nurse demonstrates critical thinking when applying the nursing process to client care. Which behavioral components would the nurse likely use during the assessment phase? Select all that apply.

Asking relevant questions Exploring ideas Recognizing issues

The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the most appropriate nursing action?

Assess the client's back visually.

An older adult client is being admitted to the hospital for treatment of a fractured hip. Which part of the nursing process would the nurse carry out first ?

Assessment

Put the phases of the nursing process in the correct order.

Assessment Diagnosis Planning Implementing Evaluation

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation?

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

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

Decide whether to continue, modify, or terminate client care.

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.

A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment?

Document this assessment based on the client's behaviors.

A hospital client has an aggressive fungal infection in the right eye that necessitates evisceration (removal of the eye). Consequently, the client requires twice-daily packing and dressing changes to the orbit. Which of the nurse's actions in the care of this client most clearly demonstrates interpersonal skills?

Ensuring the client's privacy during dressing changes and providing an explanation during the procedure

Once the nurse has administered pain medication, it is the nurse's responsibility to determine its effect and any other results. When accomplishing this follow-up with the client, the nurse is in which step of the nursing process?

Evaluation

The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What should 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.

Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing?

Evidence-based practice

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

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

Intuition can be a clinically useful adjunct to logical problem solving.

Which are characteristics of reasoning? Select all that apply.

Is based on assumptions Has a purpose Contains inferences Has implications

Which is a characteristic of person-centered care?

It is a framework for providing care.

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking.

Which are characteristics of critical thinking? Select all that apply.

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

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on 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.

The nurse enters the room of an adult client who reports postoperative abdominal pain. The client states that the pain is severe but is relieved some when getting up to go the bathroom. Which is the nurse's best determination based on this assessment?

More assessment would be beneficial to determine whether pain medication is desirable.

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

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

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing

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

Prioritize the nursing diagnoses.

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

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care.

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?

Reflection

The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client's unrelieved pain?

Repositioning the client

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis?

Risk for falls

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

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

A client is newly diagnosed with diabetes and prescribed insulin injections. The nurse identifies the client's knowledge deficiency regarding insulin injection. Which intervention is appropriate to address this deficiency?

Teach the client how to administer insulin.

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 ability to communicate clearly through documentation is a critical nursing skill. Which statements accurately describe the role of documenting in the nursing process? Select all that apply.

The client record is the chief means of communication among members of the interdisciplinary team. A nursing action not documented is a nursing action not performed. It is helpful to practice documentation while learning any given nursing activity. The content of the client report and nursing documentation helps to establish nursing priorities in practice.

The clinical nurse manager is evaluating a new nurse 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.

Which statements are true about the implementation phase of the nursing process? Select all that apply.

This phase promotes wellness and restores health. Care provided during implementation should be documented in the client's chart. Implementation is the process of carrying out the plan of care.

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 consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?

activity and rest

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

The correct progression of steps of the nursing process is:

assessment, diagnosis, planning, implementation, and evaluation.

An obese client is in the clinic to start 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 mostappropriate outcome for this nursing diagnosis for the client? The client will:

create an exercise plan that is realistic and valued.

A modern approach to the development of clinical decisions and clinical judgments is the use of human client simulators in simulation laboratories on campus. Human client simulators are best described as:

life-sized mannequins with a sophisticated computer interface.

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

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:

reflective practice.

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.