Critical Thinking and Nursing Process

The RN implements an intervention to improve a patients appetite. After implementing the intervention for two meals, the LPN/LVN notes no improvement in the patients eating. What action should the LPN/LVN take? a. Develop a new plan of care. b. Revise the patient outcome to one that is achievable. c. Collaborate on a new nursing diagnosis with the RN. d. Provide data to the RN to assist in evaluation of the plan.

ANS: D D. The role of the LPN/LVN includes data collection and assisting in evaluating outcomes. The LPN/LVN should provide new data to the RN, so they can revise the plan of care together. A. B. This is not done independently. C. A new diagnosis may be appropriate, but is not carried out independently of the RN.

The nursing staff is planning a celebratory dinner and cake for a newly licensed practical nurse. Which of the new nurses human needs is supported by these actions? a. Self-esteem b. Physiological c. Self-actualization d. Safety and security

ANS: A A. Recognizing a persons accomplishments enhances self-esteem. B. C. D. The staffs actions are not meeting physiological, self-actualization, or safety and security needs of the new nurse.

The nurse is planning a patients care based on Maslow's hierarchy of needs. Which human need should the nurse identify as requiring his or her immediate attention? a. Heart rate 38 and irregular b. Plans to return to college in a year c. Needs walker adjusted to safely ambulate d. Desire to learn how to self-inject medication

ANS: A A. According to Maslow's, basic needs or physiological needs must be met first. A heart rate of 38 and irregular is a physiological need. C. Safety and security needs are met after physiological needs have been satisfied. Safe ambulation would be addressed next. D. Self-esteem needs are met after safety and security needs have been addressed. The desire to be independent with medication injections can be addressed after safety and security needs. B. Planning to return to college is an example of self-actualization, which is a need that can be addressed last.

The nurse is planning care and setting goals for a newly admitted patient. Who should the nurse include when conducting these nursing actions? a. Patient b. Nurse manager c. Patients family members d. Patients health care provider (HCP)

ANS: A A. Planning care and setting goals are actions performed with the patient. The patient must be in agreement with the plan for it to be successful in meeting the desired outcomes. B. The nurse manager may or may not be aware of the patients care needs. C. The patients family may or may not be aware of the patients care needs. D. The focus of nursing care is different from that of the HCP.

The nurse is determining diagnoses appropriate for a patient recovering from surgery. Which nursing diagnoses should the nurse identify as the highest priority for this patient? a. Acute pain b. Impaired mobility c. Deficient knowledge d. Impaired skin integrity

ANS: A A. Using Maslow's hierarchy, pain is the highest priority nursing diagnosis for a postoperative patient. B. D. These diagnoses would be equally important after the patients pain is addressed, because they focus on physiological needs. C. This diagnosis can be addressed at a later time once physiological needs have been met.

The nurse is caring for a patient recovering from a stroke. Use the nursing process to order the observations made or actions performed while caring for this patient (AE). A. Hand grasp absent left hand B. Alteration in Cerebral Perfusion C. The patient flexed left thumb and index finger. D. Coached to squeeze rubber ball placed in left hand. E. The patient will be able to self-feed using left hand.

ANS: A, B, E, D, C A. Assessed data is the absence of a left hand grasp. B. The nursing diagnosis that would be associated with the absence of a hand grasp would be Alteration in Cerebral Perfusion. E. The goal of nursing care would be for the patient to self-feed using the left hand. D. Coaching to squeeze a rubber ball in the left hand is an intervention to improve left hand function. C. The patient flexing the left thumb and index finger evaluates the success of the intervention of squeezing a rubber ball in the left hand.

The nurse is reviewing data collected during patient care. Which data should the nurse document as objective? a. Patient is pleasant. b. Urine output is 300 mL. c. It has been a good day. d. Patients appetite is poor.

ANS: B B. Objective data are factual information such as the volume of urine output. A. This is an opinion that the nurse has about the patients behavior and is too vague to document as objective data. C. This statement is in quotations, so it is something that the patient subjectively stated. D. This is an opinion the nurse has about the patients appetite and is too vague to document as objective data.

The nurse is preparing to determine if a patient is meeting planned outcomes. What measurable information should the nurse use to make this determination? a. P-E-S format b. Objective observations c. Subjective terminology d. Open-ended time frames

ANS: B B. Measurable means that an outcome can be observed or is objective. It should not be vague or open to interpretation. A. Problem-Etiology-Symptoms (PES) format refers to nursing diagnoses, not outcomes measurement. C. Subjective terminology is the use of patient statements to support objective data. D. Open- ended time frames do not help with measurement.

The nurse is identifying outcomes for a patient with a Fluid Volume Deficit. Which outcome should the nurse use to guide the patients care? a. Patients fluid intake will be measured daily. b. Patients intake will be 3000 mL daily. c. Fluids will be at the bedside for the patient. d. Fluids the patient likes will be at the bedside.

ANS: B B. This outcome provides objective measurable data. A. C. D. These statements are nursing actions

The nurse is caring for a patient with the diagnosis of Fluid Volume Excess. Which information should the LPN/LVN use to determine if care was effective? a. Restrict the patients fluid intake. b. Measure the patients daily weight. c. Teach the patient to monitor fluid balance. d. Discuss the patients care plan with the RN.

ANS: B B. To evaluate the effectiveness of the plan of care and the actions implemented, the nurse must assess the outcome for the patients nursing diagnosis and determine if the outcome has been achieved or if revisions are needed. For this patient, a change in weight is an objective measurement for determining if interventions to address Fluid Volume Excess have been effective. A. Restricting fluid intake is an action. Evaluation is required to determine patient outcome and effective care. C. Teaching the patient to monitor fluid balance is an intervention and will not help determine the effectiveness of care. D. Although discussing the plan of care with the RN is relevant to the patients care, it will not help determine effectiveness of care provided.

The nurse identifies the diagnosis Potential for Ineffective Gas Exchange as appropriate for a patient with pneumonia. Which independent nursing actions should the nurse plan for this problem? (Select all that apply.) a. Apply oxygen, 2 liters, per nasal cannula. b. Turn and reposition in bed every 2 hours. c. Coach to deep breathe and cough every hour. d. Administer intramuscular antibiotic medication. e. Encourage to drink 240 mL of fluid every 2 hours.

ANS: B, C, E B. C. E. Independent nursing actions are those that can be implemented without an HCPs order. A. D. Interventions that need an HCPs order include administering oxygen and medication. These are collaborative interventions.

After collecting data the nurse identifies diagnoses to guide the patients care. Which diagnoses did the nurse document correctly? (Select all that apply.) a. Diabetes b. Acute pain c. Pancreatitis d. Activity intolerance e. Impaired physical mobility

ANS: B, D, E B. D. E. Acute Pain, Activity Intolerance, and Impaired Physical Mobility are nursing diagnoses. A. C. Diabetes and Pancreatitis are medical diagnoses.

The nurse is determining a patients problems. What step of the nursing process is the nurse performing? a. Assessment b. Outcome planning c. Nursing diagnosis d. Nursing intervention

ANS: C C. A nursing diagnosis is a clinical judgment about individual, family, or community response to actual or potential health problems or life processes. Nursing diagnoses are standardized labels that make an identified problem understandable to all nurses. A. Assessment is the collection of data used to identify patient problems. B. Outcome planning occurs after a patients problems have been identified. D. Interventions are provided after the problems, plan, and outcome have been identified.

The nurse is caring for a patient who is scheduled for surgery. Which data should the nurse collect to identify safety and security needs? a. Meal patterns b. Sleep patterns c. Anxiety about surgery d. Effectiveness of pain medication

ANS: C C. A threat to a persons safety and security, such as surgery, creates anxiety. The patients anxiety level will help the nurse plan care to meet safety and security needs. A, B, and D describe data used to support the patients physiological needs

While being taught to apply a topical medication, the patient begins to vomit. Which action should the nurse take to meet the patients human needs? a. Provide a clean gown before resuming the teaching. b. Position an emesis basin for patient use while teaching. c. Provide medication prescribed for nausea and vomiting. d. Wait for the vomiting to stop and begin the teaching session again.

ANS: C C. Basic physiological needs must be met first. Since the patient is vomiting, the nurse should provide the medication prescribed for nausea and vomiting. A. B. D. These actions do not take the patients physiological needs into consideration. The patient will not be able to achieve a higher level of the hierarchy before basic physiological needs are met.

The nurse is caring for a patient with a painful back injury that occurred 6 months ago. Which three- part nursing diagnosis should the nurse use to guide this patients care? a. Pain as evidenced by herniated lumbar disk b. Acute pain related to inability to sit as evidenced by muscle spasms c. Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and difficulty walking d. Acute pain related to patient pain rating of 6 as evidenced by muscle spasms and nerve compression

ANS: C C. Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and difficulty walking uses the three-part, or Problem, Etiology, and Signs/Symptoms, system with measurable data as evidence. This best guides the nurses care and evaluation of the outcome. A. This statement includes a medical diagnosis. B. D. There is not enough measurable evidence for these nursing diagnosis statements.

After identifying nursing diagnoses, the nurse plans outcomes for a patient with gastroesophageal reflux disease. Which outcome should the nurse use to evaluate this patients care? a. The patient will have less heartburn. b. The patient will sleep through the night. c. The patients esophageal burning will resolve 30 minutes after taking oral antacids. d. The patient will state that burning only occurs when eating foods high in acid content.

ANS: C C. Outcomes should be measurable and realistic for the patient; they should include an appropriate time frame for achievement. A. Outcomes should not be vague or open to interpretation, with the use of subjective words such as normal, large, small, or moderate. B. Sleeping through the night may or may not be associated with the patients problem. D. Stating that the burning only occurs when eating foods high in acid content is a patient observation that could be used for subjective data collection.

A RN delegates a patient care assignment to the LPN/LVN. Which phase of the nursing process should the LPN/LVN perform independently? a. Assessment b. Planning care c. Implementation d. Nursing diagnosis

ANS: C C. The LPN/LVN independently provides direct patient care. A. B. D. The LPN/LVN assists the RN with collecting data, formulating nursing diagnoses, determining outcomes, and planning care to meet patient needs

The nurse is using the nursing process when caring for a patient. In which order should the nurse implement this process? a. Nursing diagnosis, intervention, rationale, evaluation, planning b. Data collection, intervention, nursing diagnosis, rationale, evaluation c. Assessment, nursing diagnosis, planning, implementation, evaluation d. Data collection, evaluation, nursing diagnosis, implementation, rationale

ANS: C C. The nurse should implement the steps of the nursing process by beginning with assessment, formulating nursing diagnoses, planning care, implementing care, and then evaluating care. A. B. D. These lists do not implement the steps of the nursing process in appropriate order. Rationale is not a step in the nursing process.

A patient with a newly fractured femur reports a pain level of 8/10, and analgesic medication is not due for another 50 minutes. Which actions should the nurse take? a. Reposition the patient. b. Give the medication in 30 minutes. c. Notify the registered nurse (RN) or physician. d. Tell the patient it is too early for pain medication.

ANS: C C. The patient should not have to wait for pain relief. The LPN should inform the RN or physician, so new pain relief orders can be obtained. A. The patient who has a fractured femur is experiencing acute pain. Repositioning a patient with a new fracture is not likely to relieve pain. B. Giving the medication before the prescribed time is beyond the nurses scope of practice. D. The nurse needs to do more than expect the patient to wait for pain relief.

A patient with a family history of diabetes is experiencing high blood glucose levels, confusion, an unsteady gait, and dehydration. Which nursing diagnoses should the nurse identify as appropriate for this patients care? (Select all that apply.) a. Diabetes b. Dehydration c. Risk for falls d. Hyperglycemia e. Deficient fluid volume

ANS: C, E C. E. Deficient fluid volume and Risk for falls are nursing diagnoses related to the patients symptoms and condition. A. B. D. Diabetes, Dehydration, and Hyperglycemia are medical problems. The nurse assists with medical diagnoses; however, the nurse does not diagnose and treat medical problems.

After receiving morning report, which patient should the licensed practical nurse/licensed vocational nurse (LPN/LVN) assess first? a. A patient who needs discharge teaching b. A patient who needs assistance to ambulate c. A patient who states, No one cares about me. d. A patient who has a temperature of 106F (41.1C)

ANS: D According to Maslow's, humans basic physiological needs have the highest priority, and these patients health problems should be addressed first. Life-threatening needs are ranked first; health-threatening needs are second; and health-promoting needs are last. The elevated temperature has the greatest urgency. A, B, and C are not as high priority.

The nurse identifies the diagnosis Fluid Volume Overload as appropriate for a patient with heart failure. Which collected data should the nurse use to provide evidence for this diagnosis? a. Skin warm to the touch b. Oriented to person only c. Respiratory rate 20 and shallow d. +3 pitting edema of both feet and ankles

ANS: D D. Collected data that the nurse should use as evidence for the diagnosis are signs and symptoms related to the diagnosis. For Fluid Volume Overload, edema would be used as evidence that the patients tissue is accumulating extra fluid. A. Skin warm to the touch is an opinion. B. Oriented to person only is objective data; however, it does not apply to the nursing diagnosis. C. Respiratory rate 20 and shallow is objective data; however, it does not apply to the nursing diagnosis.

The nursing instructor is planning a teaching session on critical thinking for students. What should the instructor say when explaining critical thinking? a. Collect data concerning the patients problem. b. Think of different ways to help relieve a patients problem. c. Determine if an action worked to eliminate a patient problem. d. Use knowledge and skills to make the best decision for patient care.

ANS: D D. Critical thinking is using knowledge and skills to make the best decisions possible in patient care situations. A. Collecting data describes assessment. B. Thinking of different ways to help a patient with a problem is planning. C. Determining if an action worked to eliminate a patient problem is evaluation.

The LPN/LVN is reviewing a patients list of nursing diagnoses. Which diagnoses should the LPN/LVN identify as a priority for this patient? a. Anxiety b. Constipation c. Deficient fluid volume d. Ineffective airway clearance

ANS: D D. Ineffective airway clearance is the highest priority, because it can be life-threatening. B. C. These diagnoses are important; however they are not immediately life-threatening. A. Anxiety is the lowest priority, because physiological needs must be addressed first.

During a class discussion, two nursing students demonstrated intellectual courage. What action did the nursing students perform? a. Considered being in the other persons situation b. Expected proof that the use of restraints is safe c. Conducted additional research on the use of restraints in patient care d. Listened to each others point of view regarding the use of patient restraints

ANS: D D. Intellectual courage is looking at other points of view. A. Intellectual empathy allows a person to consider another's situation. B. Intellectual integrity is seeking the same level of proof for comparable items. C. Intellectual perseverance is continuing to search for evidence about a concern.

The nurse suspects a patient is experiencing adverse effects to a newly prescribed antihypertensive medication. After being informed that the effects are expected, the nurse remains concerned and conducts an Internet search on the patients manifestations. Which critical thinking behavior did the nurse implement? a. Sense of justice b. Intellectual courage c. Intellectual empathy d. Intellectual perseverance

ANS: D D. Intellectual perseverance is not giving up. A. A sense of justice examines motives when making decisions. B. Intellectual courage looks at other points of view, even when the nurse does not agree with them. C. Intellectual empathy understands how another person feels when making decisions.

While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes serosanguineous drainage on the patients dressing. Which statement should the nurse use to document the finding? a. Normal drainage noted. b. Moderate drainage recently noted. c. Scant serosanguineous drainage seen on dressing. d. Pale pink drainage, 2 cm by 1 cm, noted on dressing.

ANS: D D. Objective data are pieces of factual information obtained through physical assessment and diagnostic tests observable or knowable through the five senses. The nurse should document exactly what is seen. A. B. C. These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting.

The nurse approaches a person in a restaurant who appears to be experiencing respiratory distress. Which action should the nurse perform first? a. Diagnose the problem. b. Help the person lie down. c. Gather data from other people. d. Collect data about the persons condition.

ANS: D D. The first step in the nursing process is to collect data, and the patient should come first. C. The nurse can collect data from other people if necessary. A. Diagnosing the problem would occur after collecting data. B. Helping the person lie down is implementing an action to address the problem.

During morning report, the LPN/LVN is assigned a group of patients. Which patient should the LPN/LVN see first? a. A patient scheduled for magnetic resonance imaging (MRI) due to back pain b. A patient reporting constipation and stomach cramps c. A 2-day postsurgical patient reporting pain at a level of 6 d. A patient with pneumonia who is short of breath and anxious

ANS: D D. Using Maslow's hierarchy of needs and considering which patient problems are life-threatening, shortness of breath is most important. A. B. C. Problems of pain, constipation, and scheduled tests are all important, but not immediately life-threatening.

A patient with a history of respiratory disease is recovering from total hip replacement surgery. In which order should the nurse address the patients diagnoses? (Place in order from 1 to 4.) A. _____ Acute pain related to surgery B. _____ Risk for injury related to unsteady gait C. _____ Deficient knowledge related to use of a walker D. _____ Impaired gas exchange related to compromised respiratory system

ANS: D, A, B, C D. In a nursing plan of care, the patients most urgent problem is listed first. According to Maslow's hierarchy of human needs, this usually involves a physiological need, such as oxygen or water, because these are life- sustaining needs. If several physiological needs are present, life-threatening needs are ranked first; health-threatening needs are second; and health-promoting needs, although important, are last. In this case, Ineffective Gas Exchange is potentially life-threatening and would be first. A. Acute Pain is the next most urgent need. B. Risk for Injury is less critical than pain, because it is a potential problem rather than an actual problem. C. Deficient Knowledge comes last, because it is health- promoting and is considered psychosocial rather than physical/physiological.

The nurse finishes collecting data on a patient with injuries from a motor vehicle crash. Which data should the nurse document as objective? (Select all that apply.) a. Patient in no acute distress b. I cant believe I wrecked my car. c. Complains of pain when moving arms d. Oxygen saturation level 92% on room air e. Mid-forehead wound 3 cm long, oozing blood

ANS: D, E D. E. Data that can be observed are objective. Objective data would include an oxygen saturation level of 92% on room air and a wound on the forehead, 3 cm in length and oozing blood. A. The patient in no acute distress is an opinion about the patients status. B. A direct patient quote is subjective data. C. Complaining of pain when moving arms needs additional information to be objective such as the patients pain rating on a scale of 1 to 10 and the exact location of the arm pain.