Chapter 5: Nursing Process

Which question asked by the nurse demonstrates proper understanding of a functional assessment?

"Can you bathe and dress yourself?"

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?

Diagnosis

The nurse, after gathering data, analyzes the information to derive meaning. The nurse is involved in which phase of the nursing process?

Diagnosis

Which step of the nursing process involves reporting or analysis of data to identify and define health problems?

Diagnosis

A home health nurse reviews the nursing care plan with the client and family. Then they mutually discuss the expected outcomes of the nursing care to be provided. Which step of the nursing process is the nurse illustrating?

Planning

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

Which statements describe the nurse applying critical thinking to clinical reasoning and judgment in nursing practice? Select all that apply.

- The nurse is guided by standards, policies and procedures, ethics codes, and the state nurse practice act. - The nurse demonstrates use of nursing process, problem solving, and the scientific method. - The nurse identifies key problems, issues, and risks involved.

Which is an example of a subjective finding that the nurse would likely obtain when performing a review of systems (ROS)?

A client report of shooting pain up the left leg

The nurse is caring for a client in a critical care unit. The client's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac rhythm?

Cognitive and technical skills

A nursing student is practicing to develop critical thinking skills specifically in the area of theoretical knowledge. With which activity would the student most likely be involved?

Active reading

What nursing organization first legitimized the use of the nursing process?

American Nurses Association

Which action would the nurse perform in the assessment phase of the nursing process?

Asking the client whether the client has cultural preferences

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

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

Assessment Diagnosis Planning Implementation 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 are characteristics of a critical thinker? Select all that apply.

Being open to all points of view Resisting easy answers to client problems Thinking outside the box

A nurse is conducting a client interview and gathers information from secondary sources. Which sources might the nurse use? Select all that apply.

Client's children Client's caregiver Client's physcian Client's previous admission record

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

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

The nurse uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill?

Cognitive skill

The nurse has entered the room of a newly admitted client who immediately reports feeling short of breath. After identifying this as the client's problem, the nurse uses the process of scientific problem solving. Place the steps in the order the nurse would follow.

Collect assessment data. Formulate a hypothesis. Make a plan for action. Perform hypothesis testing. Evaluate.

Recording prioritized outcomes in the plan of care ensures which benefit?

Continuity of care can be provided to the client.

A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. Which behavior is the nurse demonstrating in the care of the client?

Critical reflectivity

What is a systematic way to form and shape one's thinking?

Critical thinking

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 novice nurse is engaging in reflection. The nurse would most likely be involved in which action?

Describing the events

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

Place the nursing activities in the order that they would most likely occur when a health care professional uses the nursing process.

Establishing the database Interpreting and analyzing client data Establishing priorities Carrying out the plan of care Measuring how well the client has achieved desired outcomes Modifying the plan of care (if indicated)

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 type of skills?

Ethical/legal skills

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, working on a rehabilitation floor, has obtained a pair of crutches for a client from the physical therapy department. The nurse and the 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 bestrepresents which phase of the nursing process?

Evaluation

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 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

The client is admitted with multiple injuries, including a head injury, fractured ribs, and hypoventilation. Vital signs are: BP 110/84, T. 98.8/37.1, P. 88, Resp. 28. Which is the patient care priority?

Maintain an open airway.

Benner (2000) has developed a model of skill acquisition outlining the stages of increasing expertise. How would the practitioner who uses rules to predominantly guide practice be described?

Novice

Place the stages of skill acquisition listed below in the proper order from first to last.

Novice Advanced beginner Competence Proficient Expert

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?

Nursing process

The client reports, "I have a few drinks with friends every week." Which nursing action exemplifies using a focused assessment in this case?

Obtaining data regarding the amount and frequency of drinking

A nurse is engaged in diagnostic reasoning to propose appropriate nursing diagnoses for a client. Place the steps in the order that they would occur from first to last during this process.

Organizing the existence of cues Generating possible diagnoses Comparing cues to possible diagnoses Conducting a focused data collection Validating diagnoses

The nurse is caring for a 35-year-old client who recently underwent gastric bypass surgery. The client is reporting horrible diarrhea. After a lengthy discussion, the nurse identifies that spicy food may be contributing to this problem. The nurse speaks with the staff nutritionist to work with the client to make appropriate food choices. Which best describes the nurse's discussion with the client?

Primary source information gathering

Which interpersonal skill is essential to the practice of nursing?

Promoting the dignity and respect of clients as people

What is the most beneficial use of the nursing process in addressing the needs of the client? You Selected:

Provides a universally applicable framework for nursing activities

While interviewing a client diagnosed with cirrhosis of the liver, the nurse asks about alcohol consumption. The client is hesitant to give information. What would be most appropriate for the nurse to do?

Rephrase the question in a more acceptable form.

Which statement is true of the nursing process?

Scientific problem solving can occur within the nursing process.

Which are characteristics of one who has developed critical thinking skills?

Self-aware, honest, persistent, and authentic

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which 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.

A client who has been admitted to the hospital for the treatment of a gastrointestinal bleed requires a transfusion of packed red blood cells. Which aspect of the nurse's execution of this order demonstrates technical skill?

Starting a new, large-gauge intravenous site on the client and priming the infusion tubing

Which scenario represents a nurse demonstrating the critical thinking process?

assessing whether physician help is needed

The nurse notes that the client has had a 20 mm Hg drop in systolic blood pressure in the past hour. The client is slurring words and cannot state the current date. The client has twice asked to speak with a parent, whom the nurse knows to be deceased. The nurse surmises that the client is acutely disoriented, and as such approaches an experienced nurse to ask for assistance. The nurse's thought process and actions in this scenario can best be described as:

clinical reasoning.

A nurse has gathered data through interview, observation, and physical assessment of a client and has formulated diagnostic statements. What would the nurse do during the outcome identification phase?

formulate client-focused goals

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?

inserting a peripheral IV and urinary catheter

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.

After developing the plan of care for a client, the nurse implements that plan. What would the nurse most likely use to implement it?

technical skills

Critical thinking is important in making an effective nursing judgment. Which technique would be most effective for the nursing student to adopt to improve classroom success?

turn errors into learning opportunities

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.