EXAM 2!

A nurse manager is developing a program for the unit staff to foster critical thinking. Which activity would the nurse manager implement to promote theoretical knowledge?

Encouraging staff to read current journal articles

A nurse is attempting to communicate with a client who speaks a different language and is not fluent in the nurse's language. Which nursing action would best facilitate the communication process?

Speak slowly and distinctly, but not loudly.

Educating a client on the pathophysiology of diabetes mellitus is the implementation of which skill?

Intellectual

Which situation describes the communication concept of feedback between the nurse and client?

The nurse and the client use one another's reactions to produce further messages.

A client presents to the urgent care clinic with ear pain. The client reports a medical history of trigeminal neuralgia. The nurse is not familiar with trigeminal neuralgia. When the client asks whether the two conditions could be related, which response by the nurse is best?

"I honestly do not remember specific details regarding trigeminal neuralgia; let me research it."

A nurse is engaged in the most basic level of reflection. Which question would the nurse most likely ask?

"What happened?"

Which is an important element of implementation?

Documentation

A nurse is working with a group of staff members to address the needs of a client as they develop the client's interdisciplinary plan of care. Which question if asked by the nurse addresses the standard of breadth when judging the group's thinking?

"Is there another way to look at this situation?"

The nurse is attentive and responsive to the health care needs of individual clients and ensures the continuity of care when leaving these clients. What interpersonal skill is the nurse displaying?

Developing accountability

Which action should the nurse associate with outcome identification and planning in the nursing process?

Develops an individualized plan of nursing care.

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.

The nurse should consider which client aspect as nonverbal communication?

tone of voice

A new nursing student has been surprised to learn that reflective journaling is a component of the curriculum. The student states to a colleague, "We would be better off spending our time working on our skills than writing in a journal." What benefit(s) of reflective journaling should the colleague describe to this somewhat frustrated student? Select all that apply.

"It can help you better understand your progress toward your learning goals." "Reflection through journaling can help you draw more learning out of your experiences." "Journaling can bring to mind aspects of a clinical experience that escaped you in the moment."

The nurse completes the admission process of a client to an acute care facility. The nurse should apply the communication technique of focusing by providing what response?

"You are hoping to figure out the cause of your extreme fatigue during this hospital stay."

A nurse is conscientious in applying the Quality and Safety Education for Nurses (QSEN) competencies to the provision of clinical care. To enact the value of quality improvement, the nurse should perform what action?

Advocate for changes to shift handoff so that the process is more efficient.

Which behaviors are characteristic of a nurse who is a critical thinker? Select all that apply.

Alert to context so that the need for modification can be identified and changes to the plan of care can be made Responsible and accountable for own actions

A client, who has limited finances, requires home health care for a chronic illness. For the nurse to meet the client's unique needs, the nurse must first perform what action?

Apply critical thinking skills.

A nurse demonstrates critical thinking when applying the nursing process to client care. Which behavioral components would the nurse likely use during the assessment phase? Select all that apply.

Asking relevant questions Exploring ideas Recognizing issues

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which action best demonstrates the nursing skill of 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

Which statements are true about the implementation phase of the nursing process? Select all that apply.

Care provided during implementation should be documented in the client's chart. Implementation is the process of carrying out the plan of care. This phase promotes wellness and restores health.

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

The nurse has entered a client's hospital room and noticed that the client is grimacing and reporting bladder fullness despite the presence of an indwelling urinary catheter. The nurse has collected and interpreted assessment data and believes that the catheter is occluded. When applying Tanner's model of clinical judgment, what should the nurse do next?

Choose an intervention and then evaluate the effect of the intervention.

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 health care provider Client's previous admission record

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

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. Use all options.

Collect assessment data. Formulate a hypothesis. Make a plan for action. Test the hypothesis. Interpret results. Evaluate.

The nurse is admitting a new client to the unit. To obtain the most thorough database possible, the nurse will perform which action?

Combine assessment data with all existing information

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

A nurse should have critical thinking attitudes to develop critical thinking skills. One attitude the nurse should possess is orderly thinking to do what is best. Which term best suits this attitude description?

Discipline

The newly hired nurse is collecting assessment data for an upcoming surgical procedure from a client who speaks the nurse's language as a second language. Which statement or question made by the newly hired nurse would indicate to the nurse manager that intervention is needed?

Do you have any questions about your cholecystectomy?"

Which action is performed in the implementation step in the nursing process?

Documenting the nursing care and client responses

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 is engaged in the assessment phase of the nursing process. When completing the physical exam, which techniques would the nurse likely use? Select all that apply.

Inspecting Auscultating Percussing Palpating

Which statements about the nursing process are accurate? Select all that apply.

It is important for providing individualized care to each client. It is an orderly way of solving client problems. It helps to emphasize the client's active role in making decisions.

Which are characteristics of critical thinking? Select all that apply.

It requires a conscious and deliberate effort. It requires a systematic and logical approach It involves judgments based on evidence.

The nurse enters the room of an adult client who reports postoperative abdominal pain. The client states that the pain is severe but is relieved some when getting up to go the bathroom. Which is the nurse's best determination based on this assessment?

More assessment would be beneficial to determine whether pain medication is desirable.

A nurse is using the nursing process to provide care to a client admitted to the facility. During the assessment phase, which activities would the nurse likely perform? Select all that apply.

Obtain a baseline oxygen saturation level. Check the results of the client's blood work. Obtain a weight

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

Purpose of thinking

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.

In the clinical setting, a nurse is working on developing higher-level reflection skills. With which activity would the nurse most likely be engaged?

Reevaluating experience in light of ideas

A nurse has used Tanner's clinical judgment model to frame the response to a challenging clinical situation. When enacting the final step of this process, what will the nurse do?

Reflect on-action.

The community health nurse is participating in a debrief about a critical incident that involved a physical altercation with the client in the client's home. When applying Tanner's model of clinical judgment to this situation, the debriefing exercise constitutes what component of the model?

Reflection on-action involves a debrief or postconference. It occurs after the situation and drives clinical learning. Reflection in-action happens in the moment. Noticing involves the perception of cues near the beginning of the interaction, and interpreting is characterized by assigning meaning to the cues that were noticed. Reflect on action is the FINAL process of Tanners model.

A junior nursing student has learned that clinical and simulation performance will be measured according to the Lasater Clinical Judgment Rubric. This student is in a curriculum that subscribes to what model of clinical judgment?

Tanner's clinical judgment model

The ability to communicate clearly through documentation is a critical nursing skill. Which statements accurately describe the role of documenting in the nursing process? Select all that apply.

The client record is the chief means of communication among members of the interdisciplinary team. A nursing action not documented is a nursing action not performed. It is helpful to practice documentation while learning any given nursing activity. The content of the client report and nursing documentation helps to establish nursing priorities in practice.

The nurse is preparing a care plan for a client with altered gas exchange in the lower airways. What short-term outcome is best for this client's care plan?

The client will maintain a pulse oximeter reading of greater than 94% (0.94).

types of communication

The nurse and physical therapist are engaging in interpersonal communication, which occurs between two or more people with the goal to exchange messages. Intrapersonal communication, or self-talk, is the communication that happens within the individual. Small-group communication occurs when nurses interact with two or more individuals. Organizational communication occurs when individuals and groups within an organization communicate to achieve established goals.

nurse is communicating the plan of care for a client who is unconscious. Which nursing actions best facilitate this process? Select all that apply.

The nurse is careful what is said in the client's presence because hearing is the last sense to go. The nurse assumes the client can hear and discusses things that would ordinarily be discussed.. The nurse speaks with the client before touching the client.

The nurse is using nonverbal communication when caring for a group of clients. Which situation(s) reflects nonverbal communication? Select all that apply.

The nurse is maintaining eye contact when changing a client's dressing. The nurse has a smile when being thanked for caring for a family member. The nurse assess a client is in pain from a grimace

Which statements describe the common use of problem solving in the nursing process? Select all that apply.

The scientific problem-solving method is closely related to the more general problem-solving process (the nursing process) commonly used by health care professionals as they work with clients. Today, nurses acknowledge the positive role of intuitive thinking in clinical decision making. Critical thinking in nursing can be intuitive or logical or a combination of both.

What is the purpose of the diagnosis phase of the nursing process?

To develop a prioritized list of client-centered problems

The nurse is admitting a client to the acute care unit with a diagnosis of dehydration. The client's skin turgor is poor and the mucous membranes are pale and dry. What is the rationale for the next phase in the nursing process?

To develop a prioritized list of current and possible health problems

When communicating with a client, the nurse uses reflection for which purpose?

To have the client elaborate on thoughts and feelings

An informatics nurse specialist is conducting an in-service education program for a group of staff nurses. The topic is ensuring electronic client data is secure and private. The specialist determines that the teaching was successful when the group identifies which aspect as essential to ensuring the security of electronic data when using clinical systems?

Use of strong passwords

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."

The nurse is caring for a client with right-sided weakness after having a cerebrovascular accident (CVA). While conducting the head-to-toe assessment, the nurse notices the client has redness around the right elbow. When developing the client's care plan, which problem-focused nursing concern will the nurse include?

altered skin integrity of right elbow related to immobility due to right-sided weakness

A nurse identifies the the nursing concern of altered skin integrity related to immobility as evidenced by reddened areas on the sacrum. The nurse is likely in which phase of the nursing process?

diagnosis

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which aligns with the nurse's actions?

clinical reasoning

An interdisciplinary team at a tertiary care center has been formed to identify a common model and language for clinical decision-making that is useful for all the health disciplines in the clinical area. What model is most likely to meet this team's needs?

cognitive continuum theory (CCT)

A novice nurse has entered a two-bed hospital room to discover a client acting out physically and another client reporting a new onset of chest pain. In addition, the overhead P.A. system is reporting a code blue in a nearby room. These rapid and numerous changes are likely to immediately challenge the nurse's:

cognitive load

A nursing student has drawn on resources from many organizations while learning and practicing as a student nurse. For which action will resources from the American Nurses Association be appropriate?

determining whether an advanced wound care technique is within the scope of practice

While assessing a client, the nurse notices that the client seems to be distracted from the questions being asked. The nurse attempts to identify factors that may be affecting the communication. What would the nurse identify as an internal influencing factor?

experience

An informatics nurse specialist is working as part of a team to develop and implement a new electronic documentation and reporting system at the clinic. The team has analyzed the situation, created a plan based on supporting evidence, created a design, built the program, and has worked out issues with the system. Staff who will be using the system have received education about the system and how it works, as well as how to use it. The team would proceed to which phase of the system development lifecycle next?

implement

The nurse enters the room of the client diagnosed with a cerebral hemorrhage and immediately thinks, "This client is getting worse." This is an example of the experienced nurse using

intuitive problem identification

What short-term outcome is the most appropriate to include in the care plan for a client with altered urinary elimination? The client will:

maintain urine output of 30 ml/hr.

A nurse is applying Tanner's clinical judgment model to the care they provide. What action characterizes the first step in this process?

noticing what is significant about the client's status and circumstances

A nursing student is providing care on a subacute step-down unit. The nursing student has received feedback that they are excessively tied to the rigid, stepwise performance of clinical tasks and fail to notice and accommodate the many contextual factors in client interactions. The nursing student is at what stage of Benner's humanistic-intuitive model of clinical judgment?

novice

The nurse is caring for a client who had a stroke with residual affective aphasia. What is an effective method(s) for the nurse to communicate with the client? Select all that apply.

provide the client with a tablet or whiteboard to attempt communication patiently await the client's responses after asking question have the client point to common phrases or spell with alphabet letters on a laminated form

The nurse is caring for a pediatric client with respiratory distress. Upon assessment the client has increased respirations and work of breathing (WOB). Breath sounds are adventitious, and the client has thick yellow/green drainage coming from the nose. Based on these findings, the nurse determines that this client has ineffective airway clearance related to copious amounts of thick secretions and proceeds to perform nasopharyngeal suctioning to relieve some of the secretions. If the nurse were documenting the evaluation of this intervention, what would be documented?

the amount and type of drainage suctioned from the nares, and the client's response

Several nurses are discussing their impressions of the newly implemented electronic health record with an informatics nurse specialist. They say, "There is so much information on one screen, it hard to tell what we should do first. It's not really clear." The informatics nurse specialist interprets the comments as reflecting an issue with which area?

usability