Clinical Judgement

The nurse is providing education to a group of middle school students regarding cold weather safety. One of the students asks the nurse how cold her body will get when it is cold outside waiting for the school bus. The nurse responds: "We are warm blooded so our body temperature remains relatively unchanged when exposed to cold weather for a small period of time." "When exposed to extreme cold, the body works hard to stay warm and may warm itself 1-2 degrees above normal during exposure." "You can expect your body temperature to drop about 3 degrees during your time at the bus stop." "Everyone is different so I cannot say how your body might react."

Humans are warm-blooded creatures, which means they maintain a consistent internal body temperature independent of the outside environment. The body's surface or skin temperature can vary widely with environmental conditions and physical activity. Despite these fluctuations, the temperature inside the body, the core temperature, remains relatively constant, unless the patient develops a febrile illness.

Implementation

Implementation is the step of the nursing process where your prioritized plans are carried out. Be sure to involve both the patient and family in active care. The nurse should always use therapeutic communication techniques for communication during implementation.(Notes: This is the step where we actually intervene to help them, give drugs, educate, monitor.)

Which action should the nurse associate with outcome identification and planning in the nursing process? Develops a prioritized list of nursing diagnoses Decides whether to continue, modify, or terminate nursing care Develops an individualized plan of nursing care Determines the client's health status, self-care ability, and need for nursing

In the process of outcome identification and planning, the nurse adapts the nursing diagnosis to address the client's strengths, thereby individualizing the plan of care. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care.

A client is admitted to the hospital with an abscess on the leg that will not heal after multiple treatment options as an outpatient. The nurse knows from past experiences that the appearance of this type of wound in clients heavily suggests a resistant bacterial infection and the need for contact isolation and intravenous antibiotics. The nurse begins to prepare for this admission. What type of problem solving does this exhibit? Intuitive Experiential Trial-and-error Scientific

Intuitive problem solving occurs when an experienced person makes decisions or solves problems based on experiences that the person has had that share similarities or associations. Experiential is not a defined type of problem solving. Scientific problem solving requires a systematic approach using a seven-step process similar to the nursing process. Trial-and-error problem solving occurs when solutions are tested until one that solves the problem emerges.

The nurse is preparing to document the nursing diagnoses for a client. What is the mostappropriate outcome for the nursing diagnosis of impaired gas exchange? The client will maintain a pulse oximeter reading of greater than 94% (0.94 L). The client will have clear breath sounds. The client will have decreased work of breathing. The client will maintain a respiratory rate between 12 and 20 breaths per minute.

Outcomes can be short- or long-term, and short-term outcomes should describe a single, observable, and measurable behavior. Outcomes are created to specify a resolution to the identified health problem reflected in the nursing diagnosis. Maintaining a pulse oximeter reading greater than 94% (0.94 L) specifies a resolution to gas exchange problems that occur in the lower airways. Having clear breath sounds, decreased work of breathing, and a normal respiratory rate only assures that the airway is established but not that gas exchange is taking place to its fullest extent.

Which students study the best in a group setting? Kinesthetic learners People-oriented learners Auditory learners Sensory learners

People-oriented learners are social; they prefer to study in groups rather than alone, and they enjoy the process more than focusing on the task at hand.

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

Person-centered care involves consideration of a client holistically by incorporating an awareness of the client's feelings into the provision of care. Person-centered care is different from task-oriented care in that the task-oriented nurse is only focused on completing tasks in a timely manner. Reassuring a client who is anxious about a procedure shows caring in that the nurse considers the client's feelings about the procedure and does not focus only on the procedure as a task in and of itself. Administering pain medicine, development of the plan of care, and insertion of a nasogastric tube are all important tasks but are not the best example of person-centered care.

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

Problem solving and the nursing process are not competing or mutually exclusive processes. Rather, scientific problem solving, trial-and-error, and intuition may all take place within the nursing process. One of the strengths of the nursing process is that it is applicable to all nursing areas, from medical-surgical to community health settings.

In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged? Identifying a positive situation Reevaluating experience in light of ideas Recalling a sequence of events Thinking about relationships involved

Reflection at the higher level includes reevaluating experience in the light of ideas, behavior, feelings, and values. Reflection at the basic level includes recalling the sequence of events, identifying a positive situation, and thinking about relationships involved.

A nurse is engaged in the most basic level of reflection. Which question would the nurse mostlikely ask? "How did the client value the experience?" "How did the client perceive the event?" "What happened?" "Were assumptions made correctly?"

Reflection at the most basic level begins with descriptions of events. The nurse would think about the situation, the people, and the environment and then recall what happened, including the sequence of events, both positive and negative feelings, the context of the situation, and the relationships involved. At higher levels of reflection, the nurse would ask what perceptions, judgments, and thoughts occurred; what values were placed on the experience; and what assumptions were made that may have been true or false.

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

Reflection is defined as a purposeful activity that leads to action, improvement of practice, and better client outcomes. Memorization is strict learning of material for recall. Assessment is careful observation and evaluation of a client's health status. Evaluation is the assessment and review of the quality and suitability of the care given and the client's responses to that care.

Which learner enjoys learning that takes place in the clinical setting? Active experimenters Learning-oriented students Grade-oriented students Sequential thinkers

Active experimenters enjoy clinical rotations and skills laboratories.

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? 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. Do not allow the client to review the client's own nursing diagnoses.

After performing a nursing assessment, data should be analyzed and compiled into actual and potential health problems and documented as nursing diagnoses. It is the nurse's responsibility to prioritize the nursing diagnoses, thereby prioritizing the care of the client. Resolved nursing diagnoses should be deleted from the plan of care as soon as they are resolved and replaced with new ones when appropriate. Nursing diagnoses should be written in a nonjudgmental way and in legally advisable terms, not in the nurse's own words. The plan of care is individualized for each client, and therefore the client should be aware of what is included.

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? Establish a nursing diagnosis of Altered Skin Integrity. Assess the client's back visually. Report it to the health care provider. Document the rash in the client's chart.

Assessment is the first phase in the nursing process, so the nurse should perform a visual assessment of the client's rash before proceeding to activities that pertain to later phases, such as reporting or documenting the rash or formulating a nursing diagnosis.

The nurse is caring for an underweight female 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? Monitor for allergies. Weigh client as needed. Administer a high-calorie diet, excluding wheat, rye, and oats. Administer a daily multivitamin.

Because this client is underweight and has an allergy to wheat, rye, and oats, administering a high-calorie diet and no wheat, rye, and oats would be the most appropriate intervention to meet the specific needs of this client. Administering a multivitamin, monitoring for allergies, and weighing the client as needed are generalized nursing measures and not specific to this client.

Which are characteristics of a critical thinker? Select all that apply. Acting like a know-it-all Resisting easy answers to client problems Being open to all points of view Thinking based on the opinions of others Accepting the status quo Thinking outside the box

Being open to all points of view allows for the critical thinker to consider all possibilities when problem-solving. Resisting easy answers provides the critical thinker the opportunity to explore all potential answers when problem-solving, as well as prioritization of the answers. Thinking outside the box encourages that the best possible answer to the problem is chosen, rather than relying on the same generic answer that may not work for every situation. Basing one's thinking on the opinions of others does not foster exploration of new ideas, nor does it foster critical thinking when problem-solving. Acting like a know-it-all prevents the acceptance of new ideas and collaboration. Accepting the status quo discourages the principles of critical thinking.

A nurse manager is talking with a new nurse. The nurse manager determines that the new nurse is thinking critically based on which statement? "If I give this medication, the client probably will be sleepy." "If my client gets short of breath, I'm unclear about why." "I don't know if the client understands." "I'm not sure what to do here?"

Critical thinking requires the nurse to anticipate what will be next; for example, when giving the medication, the client will probably get sleepy. Critical thinking is also promoted by replacing statements such as "I don't know" and "I'm not sure" with statements and actions to seek out the answer. Lacking the knowledge about "why" does not reflect critical thinking. As stated, critical thinking involves trying to find out the answer.

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. 0800: Client states that pain has decreased. 0730: Client states that pain is severe. Pain medication administered. 0900: Client states pain from 0730 has decreased from a 7 to a 4 after medication was administered.

Documentation using the nursing process must be accurate, timely, and relevant. In the above example, documentation at 0730 for the initial assessment is timely, it is concise when assigning a number to the client's pain level, and it is relevant to the assessment at hand and the action that the nurse took based on the assessment: pain medication administration. Documenting the client's pain as severe or decreased is not concise; a pain scale should be used. Documenting at 0900 the evaluation of the assessment and intervention is not timely.

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? Implementation Planning Assessment Diagnosis

During assessment, the nurse recognizes the existence of cues and conducts a focused data collection. During diagnosis, the nurse clusters cues, interprets the clusters, and validates the diagnoses for accuracy. Planning involves preparing a client plan of care, which directs the activities of the nursing staff in the provision of care. Implementation is the action phase of the nursing process.

Evaluation

Evaluation is the step where the nurse determines if the patient has met the goals in the patient's plan of care. If the patient did not meet the goals, then the nursing process would begin over and reassessment of the client is completed. Be sure to include reasons why the goals were not previously met and modifications to the plan of care to ensure new goals would be completed.

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

Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Diagnosing as part of the nursing process is meant to establish priorities of current and possible client health problems. Outcome identification and planning specify the nursing diagnosis to the client's strengths, thereby individualizing the plan of care.

Timed

Goals must always be timed. The nurse places a realistic time on the goal so that it can be measured.

Realistic

Goals should be realistic to the individual patient. This implies that the patient will actually be able to achieve the goals you outline within the time period specified.

Which learners will need to examine each item in their learning? Sensory learners Lumpers Splitters Kinesthetic learners

Splitters are learners who need to look at each piece to learn.

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

Teaching requires knowledge about teaching-learning principles to convey. The intellectual skills used in implementation include problem solving, decision making, and teaching.

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 Imbalanced nutrition Impaired mobility Ineffective coping

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.

Assessment

The assessment portion of the nursing process is where the nurse will collect data about the patient. This information will encompass physical findings, psychological, cultural, social, family, and nursing histories as well as accessing the medical record and obtaining diagnostic test results.A nurse should not implement interventions until a complete assessment has been done. Exceptions are only in scenarios where the patient will be at risk of immediate injury or death.

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

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.

Which is a characteristic of person-centered care? It is a framework for providing care. It involves general care for all clients. It is independent of other disciplines. It can be used in hospital settings.

The model of person-centered care is a framework for providing care. The approach is not independent of other disciplines, but is interdependent with other disciplines such as medicine, physiotherapy, surgery, etc. The model can be used in all settings and is not limited to hospital settings. Person-centered care aims to provide specific care to people based on individual needs.

Diagnosis

The nursing diagnosis is formed after completions of a comprehensive nursing assessment. Nursing diagnosis' are developed by NANDA (North American Nursing Diagnosis Association) and should be prioritized based on Maslow's Hierarchy of Needs.

ADPIE

The nursing process can be remembered by the common mnemonic ADPIE.

The correct progression of steps of the nursing process is: implementation, planning, evaluation, assessment, and diagnosis. assessment, diagnosis, planning, implementation, and evaluation. planning, assessment, diagnosis, evaluation, and implementation. diagnosis, implementation, assessment, evaluation, and planning.

The nursing process is a systematic method that directs the nurse and client and includes the following sequential steps: assessment, diagnosis, planning, implementation, and evaluation.

The Nursing Process

The nursing process is a way for the nurse to apply critical thinking skills during the care of his or her clients. The nursing process is a cyclical process that has five components: Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Individualized to the Patient

The planning stage involves setting goals that are individualized for the patient based on assessment data. Some examples of specificitty include modifying goals for age, communication ability, mobility, mentality, or any other assessment related data.

Planning

The planning step of the nursing process includes developing an individualized care plan, setting goals, and identifying expected outcomes. Setting priorities of the nursing diagnosis' is an important step in the plan of care. Outcomes of planning should be individualized to the client, realistic and measurable, and include a time frame.

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? Follow up with the client later to determine whether the client's laboratory test results improve. Analyze the data and create an individualized nursing diagnosis. Identify outcomes for the client with the client's input. Administer a prescribed medication to decrease the client's blood glucose level.

The second part of the nursing process is the analysis of data that can help determine nursing diagnoses. Because the nurse has the assessment findings of polydipsia, polyphagia, polyuria, and an increased HgbA1C level, the nurse can analyze these findings to help to determine the most appropriate nursing diagnosis. Once the nursing diagnosis is determined, then the nurse, with input from the client, can identify outcomes and interventions, such as medication administration, implement the interventions and evaluate them.

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 Surveillance Supervisory Maintenance Technical

The term "supervisory intervention" is applied in the context of overseeing a client's overall care.

A nurse is caring for a client with diabetes mellitus. The client takes insulin 2 times per day. The nurse makes sure the client's meals arrive in coordination with the insulin's effect. The knowledge used by the nurse is: creative. lacking. integrated. evaluative.

This scenario indicates the integration of a nurse's knowledge in the provision of safe client care.

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. intervention. nursing diagnosis. subjective data.

This statement is an outcome statement that focuses on the client, is realistic, and is measurable. Subjective data would include information from the client, such as complaints or reports of anxiety. Nursing diagnosis is a clinical judgment about an individual, family, or community experience/response to an actual or potential health problem. Intervention would be the action to be completed based on the nursing diagnosis and intended outcome (e.g., administering a prescribed analgesic).

The nurse is assessing the temperature of an 8-month-old infant using a tympanic membrane thermometer. The reading is 95.2°F (35.1°C). What should the nurse do next? Recheck the temperature, paying close attention to technique. Assess the skin for signs of cyanosis. Cover the infant. Ask the parent whether the child has been exposed to cold temperatures.

Tympanic membrane thermometers are noninvasive and fast to use, but studies show discrepancies between their readings and those of oral thermometers, resulting in both false-positive and false-negative readings. The nurse can minimize these discrepancies by using the same ear and device for measurement each time and by using proper technique. The other actions listed would be appropriate for the nurse to take after rechecking the infant's temperature and confirming that it actually is lower than normal.