Fundamentals Nursing Prep U Chapter 10 Blended Competencies, Clinical Reasoning, and Processes of Person Centered Care
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
A nurse is examining alternatives and judging the worth of evidence as part of preparing the plan of care for a client. The nurse would most likely be involved in which phase of the nursing process?
Planning
Which learners will need to examine each item in their learning?
Splitters
A client who has limited finances and limited capacity for education requires home health care for a chronic illness. For the nurse to provide a high level of care to this client, she must first:
implement critical-thinking skills.
Which statement best conveys the role of intuition in nurses' problem solving?
Intuition can be a clinically useful adjunct to logical problem solving.
Select the best description of how the nurse applies the nursing process in caring for clients. The nurse:
uses critical thinking to direct care for the individual client.
The nurse is assessing a 1-year-old baby. The mother states, "I'm not sure if he has a fever. I have such a hard time with my glass thermometer. It's so hard to read." The nurse's best response would be:
"There is some danger in using a glass thermometer and the mercury it contains. You might consider buying a new type of device."
The nurse is caring for a client who has been in the hospital for 7 days. When the nurse enters the room to perform the morning assessment, the client tells the nurse he can't wait to go home. What statement by the nurse demonstrates that the nurse is skilled in developing caring relationships?
"What do you miss most about being away from home?"
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 evaluated the client and found that pain was a 4 on a scale of 0 to 10. Which example of documentation most clearly communicates the initial morning assessment?
0730: Client's reports pain is a 7 on a scale of 0-10, Morphine sulfate 2 mg. IV administered.
Which learner enjoys learning that takes place in the clinical setting?
Active experimenters
The nurse is performing an assessment on a client who presents with a rash on the back that is red and raised. What would be the most appropriate nursing action?
Assess the client's back visually.
A nurse technician is assigned to take client vital signs. When making rounds, the nurse notices that one client's vital signs are very different than they were at the beginning of the shift. What is most appropriate for the nurse to do about these findings?
Assess the client's vital signs again.
An older adult client is being admitted into the hospital for treatment of a fractured hip. Which part of the nursing process would be carried out first?
Assessment
For nursing students to be successful in their educational endeavors, they must
Be actively involved with the material in the text
A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client's blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?
Determine whether the prescribed treatment was effective.
Which actions does the nurse associate with outcome identification and planning in the nursing process?
Develops an individualized plan of nursing care
A nurse identifies the following: "Impaired skin integrity related to immobility as evidenced by reddened areas on the sacrum." The nurse is most likely in which phase of the nursing process?
Diagnosis
The nurse is caring for a client who states that he hears voices in his head that tells him to do bad things. When the nurse enters the client's room, he is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment?
Document this assessment based on the client's behaviors.
The nurse is caring for an obese client that needs to be turned every 2 hours. Which nursing action is an example of reflection for action?
During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help. After the shift is over, the nurse wonders if all health care providers are using the appropriate resources when turning this client. The next day, the nurse institutes, as part of the client's plan of care, assistance with turning so that the client gets optimal care without injury to the caregivers.
The nurse is caring for a client who is postoperative and has pain that is an 8 on a scale of 0-10. There is an order for IV pain medication every 4 hours PRN. The nurse administers the prescribed pain medication to the client. What should the nurse do to assist in meeting this client's desired outcome of a pain scale score less than 4 on a scale of 0-10?
Evaluate the client's pain level after the appropriate amount of time has elapsed for the pain medication to take effect.
A nurse administers medications to a client. What step of the nursing process would the nurse perform next?
Evaluating
The nurse assesses a client's blood pressure, which was 160/90. Two hours following the administration of hydrochlorothiazide, the nurse reassesses the blood pressure at 140/78. What action has the nurse implemented?
Evaluation
According to information-processing theory, the reasoning process that proceeds from specific to general is termed
Inductive
The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and upon evaluation finds that the client continues to exhibit symptoms of deficient fluid volume. What should the nurse do next?
Modify the plan of care and interventions to meet the client's needs.
Which students study the best in a group setting?
People-oriented learners
The nursing student has been assigned to a pediatric hospital floor next week. The student understands that he or she is expected to be able to use the syringe pump with the clinical instructor when giving medications. The student has never used this pump before and is anxious. What is the most appropriate way for the student to lessen the anxiety associated with the clinical rotation?
Practice using the pump in the lab setting if it is available and with instructor permission.
What is the best example of person-centered care provided by a registered nurse?
Reassuring a client that is anxious about a procedure
Which statement is true of the nursing process?
Scientific problem solving can occur within the nursing process.
The nursing student is attending clinical rotations in the acute care facility. In order to implement the most effective care for clients what is the most appropriate action for the student to take?
apply theoretical knowledge to present clinical situations.
An obese client is in the clinic to be started on a weight loss plan. The client loves to eat. The client's favorite food is hamburgers. The client does not like to exercise. The nurse creates a nursing diagnosis of ineffective health maintenance to include in the plan of care. What is the most appropriate outcome for this nursing diagnosis for this client? The client will:
create an exercise plan that is realistic and valued.
A nurse providing care to a client questions judgments and considers other ways of thinking about the client's situation. What behaviors is the nurse demonstrating in the care of the client?
critical reflectivity.
The nurse has obtained assessment data from a client and is proceeding to the next phase of the nursing process. What would be the importance of the diagnosing phase of the nursing process?
develop a prioritized list of client-centered problems.
Which is the most appropriate outcome for the nursing diagnosis of Impaired Urinary Elimination? The client will:
maintain urine output of 30 mL/hr.
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
supervisory
A nurse demonstrates clinical reasoning during which phases of the nursing process? Select all that apply.
• Assessment • Diagnosis • Planning • Implementation • Evaluation
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.
The nurse has entered the room of a newly admitted client who immediately reports feeling short of breath. After identifying this as the client's problem, the nurse uses the process of scientific problem solving. Place the steps in the order the nurse would follow.
• Collect assessment data. • Formulate a hypothesis. • Make a plan for action. • Perform hypothesis testing. • Evaluate.
The nurse is in the evaluation phase of the nursing process when developing the plan of care for a client. What does the nurse determine this phase will include? Select all that apply
• Evaluation is the last part of the nursing process. • Evaluations should be documented daily in the client record. • The evaluation is used to determine decisions about terminating, continuing, or modifying the plan of care.
Which statements are true about informatics in nursing practice? Select all that apply.
• Nurses should value technologies that support error prevention and care coordination. • The use of informatics can help manage knowledge and mitigate error. • Utilization of information services helps to support decision-making.
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