Chapter 5: Thinking Critically to Analyze Data and Make Informed Nursing Judgments

Essential characteristics for the development of critical thinking skills include all the following except: a. Keeping an open mind b. Following instructions c. Using evidence to guide decisions d. Considering past experiences to plan appropriate actions

b. Following instructions An open mind, recognition of evidence, and reflection on past experience all contribute to critical thinking, while following instructions does not.

A nursing student is explaining to a roommate the relationship between diagnostic reasoning and critical thinking. Which of the following is the correct statement for the nursing student to make? a. "Diagnostic reasoning is a form of critical thinking used to interpret data correctly." b. "Critical thinking is a form of diagnostic reasoning used to interpret data correctly." c. "Diagnostic reasoning is used in assessment, whereas critical thinking is used in analysis." d. "Critical thinking and diagnostic reasoning are not related."

a. "Diagnostic reasoning is a form of critical thinking used to interpret data correctly." As the second step or phase of the nursing process, data analysis is a very difficult step because the nurse is required to use diagnostic reasoning skills to interpret data accurately. Diagnostic reasoning is a form of critical thinking.

A client asks why a nurse measured the blood pressure after the nursing assistant completed the measurement a few minutes ago. What should the nurse respond to the client? a. "It was done to validate the reading." b. "The first reading was measured too early." c. "The nursing assistant had difficulty with the reading." d. "The second reading was used as a guide for providing a medication."

a. "It was done to validate the reading." The second reading was to verify the data with another health care professional. A blood pressure measurement is not done "too early." Saying that the nursing assistant had difficulty with the reading could cause the client to be alarmed or to question the nursing assistant's ability to provide care. Some medication may require a blood pressure measurement however this is unlikely considering the timing of the measurements.

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a client who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered? a. Actual Nursing Diagnosis b. Risk Nursing Diagnosis c. Wellness Nursing Diagnosis d. Rule Out Nursing Diagnosis

a. Actual Nursing Diagnosis This client is having an actual problem--pain--which therefore would be classified as an actual nursing diagnosis and provides a description of the problem that the client is currently having.

The nurse has clustered assessment data on a client with cirrhosis of the liver that has altered mental status due to the accumulation of ammonia toxins. What type of priority nursing diagnosis would be indicated for this client? a. Actual nursing diagnosis. b. A wellness nursing diagnosis. c. A risk nursing diagnosis. d. A stated nursing diagnosis.

a. Actual nursing diagnosis. An actual nursing diagnosis indicates the client is currently experiencing the stated problem or has a dysfunctional pattern. This client currently has an altered mental status related to the ammonia accumulation.

The nursing instructor tells the students that in order to develop critical thinking skills there are some essential elements that must be obtained. What elements does the student need? (Select all that apply.) a. Be nonjudgmental and keep an open mind. b. Only validate data that you see, not what the client tells you. c. Use rationale to support opinions or decisions. d. Do not reflect on your thoughts, just make a decision. e. Acquire an adequate knowledge base that continues to build.

a. Be nonjudgmental and keep an open mind. c. Use rationale to support opinions or decisions. e. Acquire an adequate knowledge base that continues to build. The essential elements of critical thinking are: Keep an open mind, use rationale to support opinions or decisions, reflect on thoughts before reaching a conclusion, use past clinical experiences to build knowledge, acquire an adequate knowledge base that continues to build, be aware of the interactions of others, and be aware of the environment.

What can the nurse use to learn new information and add to their knowledge base? a. Clinical experience. b. Past experience of other nurses. c. Reading a medical-surgical textbook. d. Doing several written care plans

a. Clinical experience. The critical thinker uses each clinical experience to learn new information and to add to the knowledge base. Another important aspect of critical thinking involves awareness of human interactions and the environment, which provides cues and directly influence decisions and judgments.

What is pivotal to determining how to move from each client problem to its goals? a. Clinical reasoning process b. Positive interpretation of the client's history c. Process in collecting physical data d. Evaluation as an accurate historian of the client

a. Clinical reasoning process Clinical reasoning process is pivotal to determining how the nurse interprets the client's history and physical examination, single out the problems listed in assessment, and move from each problem to its goals and then the implementation with specific nursing interventions.

What should the nurse do prior to analyzing data collected on a client with Addison's disease? (Select all that apply) a. Collect and organize assessment data. b. Develop outcome criteria in order to meet the goals of the client. c. Validate data. d. Document data. e. Determine what steps will be taken in implementing outcomes.

a. Collect and organize assessment data. c. Validate data. d. Document data. Before beginning to analyze data, make sure accurate performance of the steps of the assessment phase of the nursing process (collection and organization of assessment data, validation of data, and documentation of data) is complete. This information will have a profound effect on the conclusions that are reached in the analysis step of the nursing process.

The nurse reviews data collected during an assessment. Which data should the nurse validate? Select all that apply. a. Data that is inconsistent with another finding b. Subjective and objective data are inconsistent c. Respiratory rate slower during sleep than while awake d. Evening temperature higher than morning temperature e. Gap between what the client said and what is in the medical record

a. Data that is inconsistent with another finding b. Subjective and objective data are inconsistent e. Gap between what the client said and what is in the medical record Conditions in which data should be validated include findings that are abnormal or are inconsistent with other findings, discrepancy between subjective and objected data collected, and a gap between what the client says now versus what was said or documented in the past. Vital signs do not need to be validated unless there is a huge discrepancy. Respiratory rates are slower during sleep. Body temperature peaks in the evening.

The nurse is formulating a wellness diagnosis for a client ready for discharge from the hospital. In order to do this, what must the nurse identify? a. Identified weakness b. Identified strengths c. Abnormal findings d. Evaluation of outcomes

b. Identified strengths Identified strengths are used in formulating wellness diagnoses. Identified potential weaknesses are used in formulating risk diagnoses and abnormal findings are used in formulating actual nursing diagnoses.

When formulating a nursing diagnosis, the format that is most useful to clearly document the client's problem is a. NANDA label (for problem) + related to + etiology + AMB (as manifested by) + defining characteristics. b. NANDA label + defining characteristics + AMB (as manifested by) the etiology. c. NANDA label + definition + defining characteristics + AMB (as manifested by) etiology. d. NANDA label + definition + etiology + AMB (as manifested by) + defining characteristics.

a. NANDA label (for problem) + related to + etiology + AMB (as manifested by) + defining characteristics. The most useful format for an actual nursing diagnosis is: NANDA label (for problem) + related to (r/t) + etiology + as manifested by (AMB) + defining characteristics.

When teaching the students about becoming effective diagnosticians, the nursing instructor includes the following common errors made by novice nurses. (Select all the apply.) a. See things as either right or wrong. b. Realize that sometimes things are a shade of gray. c. Focus only on the details. d. Maintain a broad perspective.

a. See things as either right or wrong. c. Focus only on the details. When analyzing and making diagnoses, expert nurses tend to see the broader picture and know when exceptions can be applied to the rules. Novice nurses, on the other hand, tend to see things as right or wrong, focus only on the details, and thus may miss the big picture. Experts have a broader perspective in examining the situation.

Which of the following statements is true of nursing diagnoses? a. They focus on the responses of clients to health problems and events. b. They encompass psychological rather than physiological problems. c. They are less specific but more holistic than medical diagnoses. d. They are rooted in subjective rather than objective data.

a. They focus on the responses of clients to health problems and events. A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems and life processes. They are not solely psychologically based, nor are they necessarily less specific than medical diagnoses. They are based on both subjective and objective data.

A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client? a. Unable to feel his leg b. Bleeding profusely from the wound c. Presence of lethargy d. Mild confusion

a. Unable to feel his leg Based on the conditions in which the client has been brought to the health care facility, the client's inability to feel his legs can be noted as a subjective abnormal finding. Data such as the client is bleeding profusely from the wound and the presence of lethargy and confusion should be noted as objective abnormal findings.

The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client? a. Weight gain of 3 pounds (1.5 kilograms) over 1-2 days b. Ineffective health maintenance related to having last mammogram 2 years ago c. Knowledge deficit related to lack of information regarding low-sodium diet d. Anxiety related to ineffective coping during hospitalization

a. Weight gain of 3 pounds (1.5 kilograms) over 1-2 days Nursing diagnoses are based on alterations in body system processes, lifestyle, personal issues, and specific causes. For the client with heart failure, the problem that would have the highest priority would be the weight gain of 3 pounds (1.5 kilograms) over 1-2 days. This change can related to a decline in cardiac functioning and needs to be addressed first. Once this priority problem has been investigated, other problems can be addressed. Ineffective health maintenance can be addressed last. Knowledge deficit related to lack of information regarding low-sodium diet would be the next in priority after activity intolerance because learning how to reduce sodium could help control the heart failure. Anxiety about hospitalization and inability to attend to home and work needs would be addressed after the knowledge deficit.

A nurse analyzes the data obtained from the assessment of a client. The nurse has identified and clustered the abnormal data and strengths of the client. What should the nurse do next when analyzing the data? a. Write down the hunches based on the cue cluster b. Hypothesize and generate possible nursing diagnoses c. Check the defining characteristics of the cluster to choose an accurate diagnosis d. Verify the diagnosis with the client and other health care professionals

a. Write down the hunches based on the cue cluster After the nurse has completed identifying the abnormal data and strengths, and has clustered the related data, the nurse should then write down hunches based on the cue cluster. Only after writing down the hunches based on the cue cluster can the nurse hypothesize and generate possible nursing diagnoses, check the defining characteristic of the cluster to choose an accurate diagnosis, and verify the diagnosis with the client and other health care professionals.

The nurse is reviewing the laboratory report for a client with poorly controlled diabetes. This action falls within which step of clinical reasoning? a. identifying abnormal or positive findings b. making a hypothesis about the nature of the client's problem c. interpreting the findings d. clustering the findings

a. identifying abnormal or positive findings Laboratory reports provide objective information about potential client problems. This falls within identifying abnormal or positive findings step of clinical reasoning. In order to make a hypothesis about the nature of the client's problem, the nurse will need more information to cluster the findings first and then interpret the findings in terms of probable process.

The nurse is developing goals after completing the assessment of a newly admitted medical client. The nurse would document the goals under which part of the nursing process? a. planning b. diagnosis c. implementation d. evaluation

a. planning Goal setting and interventions are part of the planning section of the nursing process.

The nurse is walking by a client's room and notices the client's pulse oximeter reads 89% on the monitor. What is the nurse's best action? a. Document the oxygen saturation level in the client's medical record. b. Enter the room and auscultate the client's lung sounds. c. Notify the healthcare provider immediately of the finding. d. Administer the scheduled diuretic as prescribed.

b. Enter the room and auscultate the client's lung sounds. The client's oxygen saturation level is low. Urgent situations warrant immediate assessment and intervention. The nurse should assess first to determine the need for interventions such as diuretic administration. The nurse then may need to contact the healthcare provider. After the client has been cared for, the nurse should document the situation.

A nursing student is learning how to use critical thinking in formulating a plan of care. The student understands which of the following to be things needed to demonstrate that the process of thinking critically has begun? (Select all that apply.) a. reserves a final opinion until further collecting data b. explores other alternatives before making a decision c. disregards literature and sound rationale when looking to support own opinion d. uses past knowledge and experience to analyze data

a. reserves a final opinion until further collecting data b. explores other alternatives before making a decision d. uses past knowledge and experience to analyze data Nurses can assess their critical thinking skills by asking themselves some of the following questions: do you reserve your final opinion until you have collected more or all of the information? Do you support your opinion with supporting data, sound rationale, and literature? Do you explore other alternatives before making a decision? Can you distinguish fact, opinion, and inference? Do you ask your client for more information or clarification when you do not understand? These are only a few questions nurses should ask when learning critical thinking skills. Disregarding the literature and sound rationale is not advisable.

A client with a 5-day history of constipation describes a sensation of "burning" in the perianal area. This information is considered which part of the assessment data? a. subjective data b. objective data c. health history d. physical examination

a. subjective data The client is describing a problem from their own perspective; therefore, this data is considered subjective. The objective data set comprises the client signs, or what the nurse observes in the assessment. The health history and physical exam are also part of the objective data set.

A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The student needs further explanation when making which statement? a. "It is important to look closely at cultural norms." b. "All clients have the same defining characteristics." c. "It is essential to look at all client responses accurately." d. "Labels for specific diagnoses do not always accurately describe diverse client responses."

b. "All clients have the same defining characteristics." The nurse should not overlook the client's culture when analyzing data collected. Patients from different cultures may be misdiagnosed because the defining characteristics and labels for specific diagnoses do not always accurately describe the human responses in their culture. Therefore, it is essential to closely look at cultural norms and responses for various diverse clients.

A client comes to the clinic for a yearly physical examination. The assessment reveals multiple lesions on the face, neck, arms, and legs. The client appears upset, starts to cry when questioned about the skin abnormalities, and asks the nurse if the problem is skin cancer. What would be the best nursing diagnosis for this client? a. Risk for anxiety related to lesions on body b. Anxiety related to lesions on body c. Readiness for enhanced emotional well-being d. Readiness for enhanced anxiety

b. Anxiety related to lesions on body A wellness diagnosis indicates that the client has the opportunity for enhancement of a health state. A risk diagnosis indicates the client does not have the problem but is at high risk for developing it. An actual diagnosis indicates that the client is currently experiencing the stated problem. In this case, the client is definitely experiencing anxiety over skin lesions being cancer.

A nurse is writing down hunches about certain cue clusters related to a client. Which of the following hunches would seem to indicate the need to generate a collaborative problem as opposed to a nursing diagnosis? a. Poorly managed stress is causing diarrhea. b. Inflamed appendix is causing severe abdominal pain. c. Lack of knowledge about the importance of vaccinations is increasing risks of illness. d. Lack of exercise is leading to obesity.

b. Inflamed appendix is causing severe abdominal pain. If the inference you draw from a cue cluster suggests the need for both medical and nursing interventions to resolve the problem, you would attempt to generate collaborative problems. An inflamed appendix, or appendicitis, typically requires a medical (surgical) intervention and thus would be a collaborative problem. The other problems listed (poorly managed stress, lack of knowledge about vaccinations, and lack of exercise) are ones that nurses can typically address on their own.

A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission? a. SBAR communication b. Medication reconciliation c. High-alert labeling d. Client teaching of side effects

b. Medication reconciliation Medication reconciliation is a preventive measure to ensure the continuity of care for a client and the continuation of medications taken at home that are necessary for the client's well being. SBAR is a communication tool to ensure appropriate information is given to the healthcare provider to care for the client. High-alert labeling is utilized to identify many sound alike medications. The teaching of side effects is crucial to informed care, yet is not the most likely cause of omission of medication from home.

A hospitalized client reports pain 10/10 one hour after receiving a dose of intravenous morphine sulfate. The next dose is not due for over an hour. What is the nurse's best action? a. Administer another dose of morphine early. b. Notify the healthcare provider. c. Tell the client he/she can not have anymore pain medication. d. Document the pain assessment findings and reassess in 30 minutes.

b. Notify the healthcare provider. Uncontrolled pain, especially after narcotic administration, requires urgent reassessment and intervention. Without an order to administer other pain medication, the nurse must notify the healthcare provider. Administering another dose of morphine outside current orders is outside the RN's scope of practice. The client may have another problem occurring that needs to be investigated and should not just be told that additional pain medication is not an option. For example, the client could be suffering from compartment syndrome, a complication compromising circulation and characterized by pain not relieved by pain medication.

A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process? a. assessment b. implementation c. evaluation d. diagnosis

b. implementation This step is implementation, because the nurse is taking appropriate action by giving oral medication. Assessment is the first step of the nursing process when the nurse collects data. Diagnosis is determining the problem. Evaluation is the final step to see if client has achieved established goals.

The nurse collects data from a client with a nonproductive cough and labored respirations at a rate of 24/minute. What other data should the nurse collect before formulating an appropriate nursing diagnosis? a. history of illness b. status of breath sounds c. rash on face d. list of present medications

b. status of breath sounds Certain cues are pointing toward a respiratory problem for this client; however, no data have been gathered on breath sounds, which needs to be done before formulating an appropriate nursing diagnosis. The rash on face, present medications, and previous illnesses do not support cues to help in formulating a diagnosis for the breathing problem.

The nurse realizes that after she confirms that the cluster data collected meet the characteristics of a certain diagnosis, the next step is to do which of the following? a. cluster more data b. tell the client what you perceive the diagnosis to be c. re-assess the client d. collect more data

b. tell the client what you perceive the diagnosis to be If after clustering the data, they meet the criteria of a particular diagnosis, the next step is to tell the client what you perceive the diagnosis to be. Collecting and clustering more data should be done prior to confirming the diagnosis. Re-assessing the client is done when the problem is either not resolved and new interventions need to be initiated or when the problem has been resolved.

The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following? a. reliable data b. too many or too few data c. valid data d. cues available to support the diagnosis

b. too many or too few data Pitfalls decrease the reliability of cues and decrease diagnostic accuracy. One set of pitfalls includes too many or too few data, unreliable data, or invalid data and an insufficient number of cues available to support the diagnosis. Valid data, reliable data, and cues that support the diagnosis are desirable.

A nurse understands that the identified strengths found during the assessment of a client are used for which of the following nursing diagnoses? a. actual diagnosis b. wellness diagnosis c. risk diagnosis d. potential strengths diagnosis

b. wellness diagnosis The nurse formulates a wellness diagnosis using identified strengths. Identified potential weaknesses help in formulating risk diagnoses. Abnormal findings are used to formulate actual nursing diagnoses. No potential strengths diagnoses have been identified.

The new graduate nurse asks the preceptor, "I keep hearing about learning to develop good critical thinking skills, but don't really understand what that is?" What is the best response by the preceptor? a. "A way to think so that you can solve problems." b. "A way of problem solving so that you can transform from a novice to expert nurse." c. "A way of processing information using to formulate conclusions or diagnoses." d. "Being open-minded in order to provide professional nursing care."

c. "A way of processing information using to formulate conclusions or diagnoses." Critical thinking is the way in which the nurse processes information using knowledge, past experiences, intuition, and cognitive abilities to formulate conclusions or diagnoses.

A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response? a. "Call the healthcare provider to change the admitting diagnosis." b. "Tell the client that insurance will not pay for observation." c. "It's acceptable for a client to be admitted for observation." d. "Refuse to admit the client without a proper medical diagnosis."

c. "It's acceptable for a client to be admitted for observation." Assessment is one of the primary reasons a client is hospitalized. It is not uncommon that a client is hospitalized entirely for observation. The healthcare provider does not need to change the diagnosis. Telling the client that insurance will not pay for observation is not a true statement for all insurance companies.

A client admitted to a health care facility for injuries received in a motor vehicle accident is given the nursing diagnosis of impaired nutrition: less than body requirement. Which type of nursing diagnosis is this? a. Wellness b. Risk c. Actual d. Syndrome

c. Actual An actual nursing diagnosis indicates that the client is currently experiencing the stated problem or has a dysfunctional pattern and that the situation requires primarily nursing interventions. In this case, the stated problem is impaired nutrition, which can be addressed by a nursing intervention such as the following: encouraging intake of high-density foods several times a day. A wellness diagnosis, or a health promotion nursing diagnosis, indicates that the client (individual, family, community) has the motivation to increase well-being and enhance health behaviors. A risk diagnosis that indicates the client does not currently have the problem but is at high risk for developing it. When a cluster of nursing diagnoses is related in a way that they occur together, a syndrome diagnosis is made.

A nurse interacts with four different clients one afternoon at the health clinic. The nurse is able to directly assist three of them and makes a referral for the fourth. Which of the following clients should the nurse refer to another professional? a. A 12-year-old boy who is having trouble self-injecting insulin b. A young pregnant woman who needs to know what prenatal vitamins she should be taking c. An elderly woman who needs daily therapy sessions to help her walk again after a hip fracture d. A preschooler who needs a flu vaccine

c. An elderly woman who needs daily therapy sessions to help her walk again after a hip fracture Referral is used for identified problems for which the nurse cannot prescribe definitive treatment. Referring can be defined as connecting clients with other professionals and resources. Teaching a client how to self-inject insulin, counseling a pregnant woman on prenatal vitamins, and administering a flu vaccine are all interventions that a nurse can easily accomplish. Providing daily therapy sessions to help an elderly woman walk again after a hip fracture, however, would be beyond the scope of practice of the nurse and should be referred to a physical therapist.

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan? a. Discuss the plan of care with all of the health care providers involved. b. Share the assessment and plan with the client's primary health care provider. c. Ask the client for opinions and willingness to proceed with the interventions. d. Identify the needs of the client's family in relation to the priority problem.

c. Ask the client for opinions and willingness to proceed with the interventions. The plan of care should be agreeable to the client. Before finalizing the plan, it is important for the nurse to share the information with the client and seek out opinions and willingness to proceed with the interventions. Although discussing the plan of care with the all health care providers involved, involving the client in the process is the only way to know if the goals are realistic for his unique needs. Sharing the assessment and plan of care with the client's primary health care provider will only be necessary once the client has voiced his opinion and willingness to proceed with the interventions. The client's family should be involved in the plan of care and likely serve to make it more effective. The client must agree first and demonstrate willingness prior to discussing it with the family.

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step? a. The nurse must be an expert in her field in order to interpret data accurately. b. Final opinions or judgements must be made rapidly. c. Diagnostic reasoning skills are required to interpret data accurately. d. Opinions and comments are not relevant in making accurate interpretations of data.

c. Diagnostic reasoning skills are required to interpret data accurately. As the second step or phase of the nursing process, data analysis is a very difficult step because the nurse is required to use diagnostic reasoning skills to interpret data accurately.

You are the office nurse admitting a new client to the clinic. You have gained your client's trust, gathered a detailed history, and finished your portion of the physical examination. What is your next step in caring for this client? a. Formulate nursing diagnoses b. Order the appropriate laboratory tests c. Identify the client's problems d. Notify the physician of your findings

c. Identify the client's problems During the time spent with your client, you have gained your client's trust, gathered a detailed history, and completed the requisite portions of the physical examination. You have reached the critical step of formulating your Assessment, Nursing Diagnosis, and Plan. You must now analyze your findings and identify the client's problems, then share your impressions with the client, eliciting any concerns and making sure that he or she understands and agrees to the steps ahead. Finally, you must document your findings in the client's record in a succinct and legible format that communicates the client's story and your clinical reasoning and plan to other members of the health care team.

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse? a. Have the UAP retake the blood pressure b. Notify the physician c. Recheck blood pressure in 30 minutes d. Reassess blood pressure

d. Reassess blood pressure The nurse can delegate the monitoring and documenting of specific assessments to UAPs; but the nurse always retain the responsibility to interpret delegated assessment data to evaluate the client's condition. The nurse should retake the blood pressure immediately as it is abnormally low for this client. Having the UAP retake the blood pressure does not allow the nurse to evaluate the client or assess the accuracy of the UAP's ability to take a blood pressure. The physician should not be notified until the blood presser has been reassessed.

Select the following nursing diagnosis that is correctly stated. a. Risk for Impaired Skin Integrity related to immobility, bedrest, pain in legs, and the client states "I will not go to Physical therapy." b. Risk for Impaired Skin Integrity related to immobility as manifested by constant bedrest and the inability to ambulate the client twice a day. c. Risk for Impaired Skin Integrity related to immobility secondary to right-sided paralysis, dehydration, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin. d. Risk for Impaired Skin Integrity related to bedrest, lack of time to ambulate client, right-sided paralysis, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin.

c. Risk for Impaired Skin Integrity related to immobility secondary to right-sided paralysis, dehydration, and reluctance to participate in physical therapy as manifested by reddened coccyx and very dry skin. A risk diagnosis describes a situation in which an actual diagnosis will most likely occur if the nurse does not intervene. In this case, the client does not have any symptoms or defining characteristics that are manifested, thus a shorter statement is sufficient: Risk for + diagnostic label + r/t + etiology.

After collecting subjective and objective data for the admission database, what is the nurse's next action? a. Set nurse-driven goals for the client. b. Evaluate effectiveness of nursing actions. c. Validate the client's identified problems. d. Discuss the action plan with the client.

c. Validate the client's identified problems. The nurse should develop a plan of care while adhering to the nursing process. After assessment, the client's problems should be validated. Mutual goal setting is recommended versus nurse-driven goal setting. Nursing actions should not be implemented before the plan of care is developed. The plan of care can not be completed until the client's problems are validated and mutual goals are set.

The nurse is working with a 14-year-old girl who has told the nurse that she would like to try getting to bed a little sooner to get a full night's sleep and have more energy at school. The nurse diagnoses her with the following: Readiness for enhanced sleep related to client's expressed desire to go to bed earlier. Which type of nursing diagnosis is this? a. Actual b. Risk c. Wellness d. Syndrome

c. Wellness Health promotion diagnoses represent those situations in which the client does not have a problem but is at a point at which a higher level of health can be attained. In other words, this client has the desire to increase her well-being and actualize her human potential. This type of diagnosis is often worded readiness for enhanced. It indicates an opportunity to make greater, to increase quality of, or to attain the most desired level of function in the area of the diagnostic category. The other answers clearly do not describe this diagnosis.

A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information? a. Collaborative problem b. Risk diagnosis c. Wellness diagnosis d. Referral to dietitian

c. Wellness diagnosis A wellness diagnosis indicates that the client is ready to make changes to enhance his healthy state. The client states that he wants to lose weight and increase his exercise routine. A collaborative problem is one that suggests the need for both medical and nursing interventions to resolve the problem. A risk diagnosis indicates that the client does not currently have the problem but is at high risk for developing it. A referral, in which the nurse connects the client with other professionals and resources, is not necessary unless the nurse cannot assist the client with his needs.

A nursing student demonstrates understanding of the different types of nursing diagnoses when choosing which of the following to be an actual diagnosis? a. risk for impaired skin integrity b. readiness for enhanced skin integrity c. impaired skin integrity d. risk for infection

c. impaired skin integrity Risk for impaired skin integrity and risk for infection are both "risk for" diagnoses, while readiness for enhanced skin integrity is a wellness diagnosis. The only actual diagnosis is impaired skin integrity.

The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following? a. nursing intervention b. nursing rationale c. nursing diagnosis d. data organization

c. nursing diagnosis Data analysis is referred to as the diagnostic phase of the nursing process because the end result is the identification of a nursing diagnosis. A nursing intervention is done during the implementation phase, nursing rationale is identified when choosing the interventions, and data organization must be done during the collection of the data while still in the assessment phase.

A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data? a. Reports of hair loss b. Worried about appearance c. Itching sensation all over body d. Anxious appearance

d. Anxious appearance Based on the data gathered from the client, the nurse can classify the anxious appearance of the client as an objective abnormal finding. Complaints of hair loss and having an itching sensation are information provided by the client, and worrying about her appearance is an inference the nurse is making; all of these are subjective abnormal findings.

Which of the following events during the assessment process most indicates a need for validation? a. An apparently healthy client exhibits an abdominal scar suggestive of an open appendectomy in the past. b. A client begins crying as he tells the examiner about the numerous stressors in his life. c. A client complaining of flu-like symptoms has an oral temperature of 38.4°C. d. The client denies feeling upset or anxious about her recent cancer diagnosis but fidgets throughout the interview and assessment.

d. The client denies feeling upset or anxious about her recent cancer diagnosis but fidgets throughout the interview and assessment. A client who denies anxiety, yet appears upset, indicates an incongruity between subjective and objective data and would require validation. The other answers do not indicate inconsistencies or incongruities in findings that would require particular validation.

A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to a. formulate too many nursing diagnoses for the client and family. b. include too much data about the client in the history. c. obtain an insufficient number of cues and cluster patterns. d. quickly make a diagnosis without hypothesizing several diagnoses.

d. quickly make a diagnosis without hypothesizing several diagnoses. A beginning nurse attempts to make accurate diagnoses but, because of a lack of knowledge and experience, often finds that he or she has made diagnostic errors.

The nursing student demonstrates understanding of the different types of client problems when he identifies which of the following to be a collaborative problem? a. risk for loneliness b. deficient knowledge c. body image disturbance d. risk for complication: pneumothorax

d. risk for complication: pneumothorax Risk for loneliness, deficient knowledge, and body image disturbance all are problems that the nurse can intervene and treat independently. Risk for developing a pneumothorax is a collaborative problem that must be treated through physician interventions as well as nursing interventions.

One characteristic of a nurse who is a critical thinker is the ability to a. form an opinion quickly b. offer advice to clients. c. be right most of the time. d. validate information and judgments.

d. validate information and judgments. One characteristic of a critical thinker is the ability to validate information and judgments with experts in the field.