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

Which action exemplifies the purpose of evaluation in the nursing process? Decide whether to continue, modify, or terminate client care. Develop an individualized plan of client care. Develop a prioritized list of nursing diagnoses. Determine the client's health status, self-care ability, and need for nursing.

Decide whether to continue, modify, or terminate client 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 Health promotion Nutrition Self-perception

Activity and rest

A nurse technician is assigned to take clients' vital signs. When making rounds, the nurse notices that one client's vital signs are very different from what they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings? Assess the client's vital signs again. Call the health care practitioner for new orders. Document the vital signs in the client's chart. Ask the nurse technician whether the vital signs are correct.

Assess the client's vital signs again.

A nurse is educating a pregnant client in preterm labor on the use of the client's home monitoring equipment and medications. Which factor could impede the client's ability to learn? Intelligence Preparation Previous knowledge Anxiety

Anxiety

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: Clinical judgment Clinical reasoning Critical thinking Blended competencies

Clinical judgment Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients.

Which activity is the clearest example of the evaluation step in the nursing process? Taking a client's blood pressure on both arms at the beginning of a shift Giving the client an as-needed dose of captopril in light of an abnormal 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

Checking the client's blood pressure 30 minutes after administering captopril

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? Precision Clarity Relevance Accuracy

Clarity

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 most appropriate outcome for this nursing diagnosis for the client? The client will: create an exercise plan that is realistic and valued. exercise every day for at least 30 minutes. only eat three meals per day. stop eating meat and walk every day after dinner.

Create an exercise plan that is realistic and valued. Outcomes should be realistic and valued by the client and family. If this client creates an exercise plan that the client values and is realistic, then the client will be more likely to meet the outcome. Exercising every day, only eating three meals per day, or excluding meat from the diet may not be realistic or valued by the client who openly acknowledges liking to eat and does not like to exercise.

A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is most likely in which phase of the nursing process? Assessment Diagnosis Planning Implementation

Diagnosis The statement reflects a nursing diagnosis, which provides the basis for selecting interventions to achieve positive client outcomes. Assessment involves the collection of data. Planning involves preparing a client plan of care, which directs activities of the nursing staff in provision of client care. Implementation involves the actual initiation of the plan, evaluation of the response to the plan, and recording of nursing actions and client response to the actions.

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

Which statements are true about the implementation phase of the nursing process? Select all that apply. Implementation is the process of carrying out the plan of care. Care provided during implementation should be documented in the client's chart. All interventions carried out during this phase must be accompanied by a physician's order. This phase promotes wellness and restores health. Implementation is only carried out by nursing professionals.

Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health. Care provided during implementation should be documented in the client's chart. The implementation phase is the phase of the nursing process in which the plan of care is carried out. It is designed to promote wellness and restore health to clients through interventions that are collaborative and nursing driven. Not all interventions included in this phase have to be accompanied by a physician's order. Interventions are collaborative in that more than nursing professionals are involved in restoring health to the client.

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. Pneumonia Heart failure Ineffective coping Imbalanced nutrition Impaired mobility

Ineffective coping Imbalanced nutrition Impaired mobility The North American Nursing Diagnosis Association (NANDA)-International defines nursing diagnosis as "a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes." A medical diagnosis describes a disease, whereas a nursing diagnosis describes an individual, family, or group response to an actual or potential health problem. A nursing diagnosis provides the basis for selection of nursing interventions to achieve positive client outcomes.

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill? Intellectual Technical Interpersonal Visual

Intellectual Explanation: Teaching requires knowledge about teaching-learning principles to convey. The intellectual skills used in implementation include problem solving, decision making, and teaching. Chapter 13: Blended Competencies, Clinical Reasoning and Processes of Person-Centered Care - Page 304-305

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? Systematic Interpersonal Dynamic Universally applicable in nursing situations

Interpersonal All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process.

Which statement best conveys the role of intuition in nurses' problem solving? Intuition can be a clinically useful adjunct to logical problem solving. Intuition is an unreliable mode of thinking that should be avoided. In experienced nurses, intuition can be a valid replacement for scientific problem solving. Intuition is reliable when those nurses implementing it have a special "gift."

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

Which statement best conveys the role of intuition in nurses' problem solving? Intuition is reliable when those nurses implementing it have a special "gift." Intuition can be a clinically useful adjunct to logical problem solving. Intuition is an unreliable mode of thinking that should be avoided. In experienced nurses, intuition can be a valid replacement for scientific problem solving.

Intuition can be a clinically useful adjunct to logical problem solving. Creative, intuitive thinking can be useful supplements to more "in-the-box" methods of problem solving. While it should not be discouraged outright, it should also not be thought of as a replacement for logical or scientific problem solving. Intuition is not dependent on a special "gift" but is thought to be a product of experience and unconscious pattern recognition.

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.

Which statements are true about informatics in nursing practice? Select all that apply. Utilization of information services helps to support decision making. Informatics only involves documentation of timely and accurate charting. The use of informatics can help manage knowledge and mitigate error. Computers do not help with communication, but deter it because of the lack of personal interaction. Nurses should value technologies that support error prevention and care coordination.

Nurses should value technologies that support error prevention and care coordination. The use of informatics can help manage knowledge and mitigate error. Utilization of information services helps to support decision making.

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? Diagnosis Planning Implementation Evaluation

Planning Explanation: During the planning phase, the nurse examines alternatives and judges the worth of evidence using this information to develop the plan of care for the client. During diagnosis, the nurse analyzes the assessment information to identify actual or potential responses to health problems. During implementation, the nurse carries out the plan of care. During evaluation, the nurse determines outcome attainment, revises plans, and identifies a client's perception of results.

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? Do not allow the client to review the client's own nursing diagnoses. Add a new nursing diagnosis in the nurse's own words to individualize the plan of care. Prioritize the nursing diagnoses. Keep resolved nursing diagnoses as part of the plan of care in case the related problems return.

Prioritize the nursing diagnoses.

The registered nurse (RN) is receiving a shift report from another RN about a client admitted for dehydration. In the report, the departing RN indicates that the client has been prescribed intravenous fluids and an antibiotic. The oncoming RN asks why the antibiotic has been prescribed. This is an example of which consideration involved in the process of critical thinking? Purpose of thinking Problem solving Helpful resources Potential problems

Purpose of thinking

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? Patient-centered care Evidence-based practice Quality improvement Informatics

Quality improvement Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

Which is the best example of person-centered care provided by a registered nurse? Development of a plan of care for a new admission Insertion of a nasogastric tube for gastric decompression Reassuring a client who is anxious about a procedure Administration of pain medication every 4 hours to a client who is postoperative

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? After turning the client alone, the nurse realizes that the nurse should have insisted on having help. During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. The nurse decides to turn the client every 4 hours because everyone is too busy to help.

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. There are three types of reflection as defined by Schon: reflection-in-action, reflection-on-action, and reflection-for-action. Reflection-for-action is the desired outcome of the first two types and helps the person to think about how future actions might change as a result of the reflection. When the nurse realizes the need for help turning the client when first attempting to turn the client, this is reflection-in-action. When reflecting whether everyone is using appropriate resources, this is reflection-on-action. When adapting the client's plan of care based on these other reflections, this is reflection-for-action. Turning an obese client without assistance is unsafe and resources should be used. The client's outcomes should not be jeopardized by altering the plan of care due to the time constraints of staffing.

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

Reflection

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? Pneumonia Hypertension Risk for falls Congestive heart failure

Risk for falls

Which statement is true of the nursing process? Trial-and-error problem solving is an efficient use of the nurse's time. Scientific problem solving can occur within the nursing process. It is a valid alternative to using intuition to respond to nursing situations. It is more appropriate in medical surgical settings than community health care.

Scientific problem solving can occur within the nursing process.

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? Travelbee's Watson's Benner's Swanson's

Swanson's Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility." Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model, and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted.

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 does not involve client assessment. Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. Only factors that positively affect the outcome should be identified during evaluation. The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.

The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care. Evaluation is the last part of the nursing process. Evaluations should be documented daily in the client's record. The evaluation phase, which is the last phase of the nursing process, measures the extent to which the client has achieved outcomes and drives the termination, continuation, or modification of the plan of care. Evaluation does involve nursing assessment to determine whether the client has met the outcome. The nurse should identify both factors that positively and negatively affect the outcome to assist with meeting the client's outcomes, and evaluation findings should be documented daily in the client's record.

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? The nurse judges whether the patient database is adequate to address the problem. The nurse considers whether or not to suggest a counseling session for the patient. The nurse reassesses the patient and decides how best to intervene in her care. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

The nurse reassesses the patient and decides how best to intervene in her care. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use? Intuitive thinking Scientific problem solving Critical thinking Trial-and-error problem solving

Trial-and-error problem solving

creative thinking

a process involving imagination, intuition, and spontaneity—factors that underpin the art of nursing

clinical reasoning

a specific term usually referring to ways of thinking about patient care issues (determining, preventing, and managing patient problems); for reasoning about other clinical issues (e.g., teamwork, collaboration, and streamlining work flow); nurses usually use critical thinking

standards for critical thinking

clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for the purpose), and fair

intuitive problem solving

direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible

critical thinking indicators

evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice

nursing process

five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating

concept mapping

instructional strategy that requires learners to identify, graphically display, and link key concepts

The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse? involving the client with all the steps of the process in care development requiring the client to evaluate the plan of care after implementation implementing the standard plan of care for all clients with diabetes mellitus ensuring the client is informed after decisions are made with care delivery

involving the client with all the steps of the process in care development. Because the plan of care should be client-centered, the client should be directly involved with all phases of the creation of the care plan. This will involve assessing the learning needs of the client as well as goal setting, implementation, and evaluation. The client should be involved and not just informed of decisions regarding care during the evaluation phase. The client may be involved with the evaluation but the nurse will assess to determine if the plan of care is effective and if the client's goals are being met. Standard plans of care do not address the needs of the individual and should be tailored to the individual client.

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. It functions independently of nursing standards, ethics, and state practice acts. It is based on the principles of the nursing process, problem solving, and the scientific method. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. It is not designed to compensate for problems created by human nature, such as medication errors. It is constantly re-evaluating, self-correcting, and striving for improvement. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

it is based on the principles of the nursing process, problem solving, and the scientific method. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. It is constantly re-evaluating, self-correcting, and striving for improvement. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve

trial-and-error problem solving

method of problem solving that involves testing any number of solutions until one is found that works for that particular problem

person-centered care

model of patient care based on holistic roots in which the nurse or other caregiver uses every clinical encounter to assess how the person is doing and to communicate respect, compassion, and care

caring

moral imperative that guides nursing praxis (education, practice, and research); action and competencies that aim toward the good and welfare of others

reflective practice

occurs when the caregiver has a profound awareness of self, and one's own biases, prejudgments, prejudices, and assumptions, and understands how these may affect the therapeutic relationship

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. objective data. outcome. intervention.

outcome.

decision making

purposeful, goal-directed effort applied in a systematic way to make a choice among alternatives

clinical judgment

refers to the result (outcome) of critical thinking or clinical reasoning; the conclusion, decision, or opinion a nurse makes

therapeutic relationship

relationship between the caregiver and patient that is focused on promoting or restoring health and well-being of the patient

Quality and Safety Education for Nurses (QSEN)

stands for Quality and Safety Education for Nurses, a project for preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the health care systems within which they work

scientific problem solving

systematic problem-solving process that involves (1) problem identification, (2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6) interpretation of results, and (7) evaluation resulting in conclusion or revision of the study

thoughtful practice

the care of a patient by a clinician who utilizes clinical reasoning and reflective practice to guide thoughtful actions and person-centered processes of care

blended competencies

the set of intellectual, interpersonal, technical, and ethical/legal capacities needed to practice professional nursing

critical thinking

thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned; a systematic way to form and shape one's thinking that functions purposefully and exactingly

Informatics

use information and technology to communicate, manage knowledge, mitigate error, and support decision making