Prep U: Ch 13: Blended Competencies

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?

Assessment explanation: 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.

While working as part of an interdisciplinary group developing a client's plan of care, a nurse asks the question, "Can you give me an example?" The nurse is demonstrating which standard for judging thinking?

Clarity explanation:The nurse's question reflects clarity, or the need for more information. Accuracy would be reflected in questions about the information being true. Precision is reflected by questions asking for more details or specifics. Relevance would be reflected by questions related to how something connects to the issue.

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." explanation: Once common, glass mercury thermometers are no longer being used due to the dangers of exposure to mercury.

A nursing student asks his nursing professor how much time is required for studying to be successful in his nursing classes. The nursing professor provides the student with this general rule of studying time

1 hour of class, then 2 hours of studying explanation: For every hour a student spends in class, he or she should spend 2 hours studying.

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?

Assess the client's back visually. explanation: 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 developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client's musculoskeletal health problems?

Activity and rest explanation: A nursing diagnosis should be based on the collection of data from the client and should contain a precise statement related to the client's health problems. The question stem specifies that the nursing diagnosis should be based on the client's musculoskeletal issues; therefore, the domain of activity and rest would be most pertient for a nursing diagnosis. The domains of health promotion, nutrition, and self-perception are less relevant than activity and rest to a client with a musculoskeletal injury.

A nurse has identified a nursing diagnosis of "Imbalanced nutrition: less than body requirements related to continued weight loss despite adequate intake." During the implementation phase of the nursing process, which activities would be appropriate for the nurse to perform in care of this client? Select all that apply.

Administer 100 mL of nutritional supplement as ordered at bedtime. Ask the family to bring in a home-cooked meal. Contact a dietician to perform a calorie count. explanation: During implementation, the nurse would institute actions to address the nursing diagnosis. These actions would include contacting the dietician to perform a calorie count, asking the family to bring in a home-cooked meal, and administering the nutritional supplement. Comparing weights and changing the outcome would occur during the evaluation phase. Gathering subjective and objective data is part of the assessment process.

The nurse is caring for an underweight 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?

Administer a 2,500-calorie (10,460-kJ) diet, excluding wheat, rye, and oats explanation: Because this client is underweight and has an allergy to wheat, rye, and oats, administering a diet with 2,500 calories (10,460 kJ) 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.

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?

Analyze the data and create an individualized nursing diagnosis. explanation: 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 analzye 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.

Put the phases of the nursing process in the correct order.

Assessment Diagnosis Planning Implementation Evaluation explanation: The correct order of the phases of the nursing process is: assessment, diagnosis, planning, implementation, and evaluation.

A nurse is caring for a postoperative client 1 day after a total abdominal hysterectomy. Which nursing intervention best demonstrates caring in this situation?

Assisting the client to sit up in a chair explanation: Caring skills are nursing interventions that restore or maintain a person's health and may involve actions as simple as assisting with activities of daily living--the acts that people normally do every day, such as bathing, grooming, dressing, toileting, and eating. Assisting the client to sit up in the chair is an example of this type of caring behavior. The other options are important nursing tasks, but they are not demonstrating the art of caring.

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. explanation: The implementation phase is the phase of the nursing process in which the plan of care is carried out. It is designed to promote wellness and restore health to clients through interventions that are collaborative and nursing driven. Not all interventions included in this phase have to be accompanied by a physician's order. Interventions are collaborative in that more than nursing professionals are involved in restoring health to the client.

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.

Check the results of the client's blood work. Obtain a baseline oxygen saturation level. Obtain a weight explanation: During the assessment phase, the nurse evaluates the client's health state, collecting subjective and objective data. Assessment occurs through observing, interviewing, and examining the client and interpreting laboratory data and diagnostic tests. Therefore, obtaining a baseline oxygen saturation level and checking the blood work results would be considered assessment. Administering prescribed medications and performing passive range of motion exercises would be interventions that are performed during implementation. Obtaining a weight is part of the objective assessment

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 explanation: Measuring the client's blood pressure after performing an intervention such as drug administration determines the extent to which the client has achieved the outcome desired, which in this case is lowered blood pressure. Initially checking the client's blood pressure is an example of assessment, whereas recognizing it as an anomaly constitutes diagnosis. Administering the drug is a form of implementation.

Which action exemplifies the purpose of evaluation in the nursing process?

Decide whether to continue, modify, or terminate client care. explanation: 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.

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. explanation: The sequence of the nursing process is assessment, diagnosis, planning, implementation, and evaluation. Checking skin turgor is an assessment. Formulating a care plan is part of planning. Administration of additional fluid occurs during implementation. The nurse evaluates whether the intervention was effective, as demonstrated by a rise in blood pressure and a decline in pulse rate.

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.

Impaired mobility Imbalanced nutrition Ineffective coping explanation: 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.

A nurse is concerned about the requirements needed to complete all of her courses successfully. Which of the following factors would assist her to be successful?

Implement time-management skills explanation: Time management significantly affects how well a person accomplishes his or her goals.

Which stage of the nursing process enables the nurse to compare the actual outcomes with the expected outcomes?

Evaluation explanation: Evaluation is the assessment and review of the quality and suitability of the care given, and the client's responses to that care. Assessment is careful observation and evaluation of a client's health status. Planning involves setting priorities, defining expected and desired outcomes (goals), determining specific nursing interventions, and recording the plan of care. Implementation means carrying out the written plan of care, performing interventions, monitoring the client's status, and assessing and reassessing the client before, during, and after treatments.

Which statement best conveys the role of intuition in nurses' problem solving?

Intuition can be a clinically useful adjunct to logical problem solving. explanation: Creative, intuitive thinking can be useful supplements to more "in-the-box" methods of problem solving. While it should not be discouraged outright, it should also not be thought of as a replacement for logical or scientific problem solving. Intuition is not dependent on a special "gift" but is thought to be a product of experience and unconscious pattern recognition.

Which statement regarding critical thinking in nursing is true?

It is a systematic way of thinking. explanation: Critical thinking is a systematic way of thinking that involves purposeful, outcome-directed thinking. Critical thinking makes judgments based on evidence rather than conjecture. Providing a foundation for evaluation and quality improvement, showing trends and patterns in client status, and supplying validation for reimbursement are functions served by documentation.

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. explanation: The nursing process is an orderly, systematic, problem-solving approach to giving individualized care. Nurses use it in all settings with clients of all ages to identify and treat human responses to potential and actual health problems, not to identify medical diagnoses. It requires the nurse to incorporate the uniqueness of each individual, leading to individualized care. The nursing process also complements the current role of consumers in health care, in which clients play an active role in decisions affecting their health.

The nurse is caring for a client with a nursing diagnosis of deficient fluid volume. The nurse has implemented the plan of care and on 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. explanation: The nurse should review the plan of care and its implementation periodically and, as needed based on evaluation, modify them to meet the client's needs. Because this client continues to exhibit symptoms identified by the nursing diagnosis, the implementation should be modified to better meet the client's needs and outcomes. Because the original nursing diagnosis appears to be accurate, there is no indication that it falsely identifies the client's problem or that another one is needed. There is no need to reassess the client for more symptoms of deficient fluid volume because it is evident that the client has this problem.

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?

Nursing process explanation: Although clinical reasoning, reflection, and experience are important components of nursing, the nursing process is recognized as the method of practicing nursing. It is the model on which professional nursing standards are based. Although it sometimes is criticized for not being adaptable to the changing health care environment, the nursing process remains the almost universally accepted method for providing nursing care.

Which is the most appropriate example of the assessment phase of the nursing process?

Palpating a mass in the right lower quadrant of the abdomen explanation: Palpation of a mass in the abdominal cavity is an example of assessment in the nursing process through collecting data that determine the need for nursing care. Documentation of medication administration is an intervention. Evaluating the temperature of a client given medication for a fever is a better example of evaluation through assessment. Including a nursing diagnosis in the plan of care is part of determining actual and potential health problems.

Which students study the best in a group setting?

People-oriented learners explanation: 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.

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 explanation: During the planning phase, the nurse examines alternatives and judges the worth of evidence using this information to develop the plan of care for the client. During diagnosis, the nurse analyzes the assessment information to identify actual or potential responses to health problems. During implementation, the nurse carries out the plan of care. During evaluation, the nurse determines outcome attainment, revises plans, and identifies a client's perception of results.

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing explanation: Determining the correct length of the NG tube to insert is an example of the planning that is necessary to conduct this nursing action. The actual insertion of the NG tube would constitute implementation. Assessment would be checking that after insertion, the NG tube is properly working. Diagnosing is gathering the evidence that the client needs an NG tube. Evaluation would be determining whether the outcome associated with inserting the NG tube has been accomplished.

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?

Prioritize the nursing diagnoses. explanation: 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.

Which is the best example of person-centered care provided by a registered nurse?

Reassuring a client who is anxious about a procedure explanation: 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.

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action?

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client's plan of care. explanation: There are three types of reflection as defined by Schon: reflection-in-action, reflection-on-action, and reflection-for-action. Reflection-for-action is the desired outcome of the first two types and helps the person to think about how future actions might change as a result of the reflection. When the nurse realizes the need for help turning the client when first attempting to turn the client, this is reflection-in-action. When reflecting whether everyone is using appropriate resources, this is reflection-on-action. When adapting the client's plan of care based on these other reflections, this is reflection-for-action. Turning an obese client without assistance is unsafe and resources should be used. The client's outcomes should not be jeopardized by altering the plan of care due to the time constraints of staffing.

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

Reflection explanation: 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.

The nurse employs interpersonal skills of communication when caring for and interacting with clients. Which is the best example of establishing a therapeutic nurse-client relationship?

Show respect for the client, and engage in open communication in getting to know the client. explanation: Respect for the client's dignity, and establishing a caring relationship, is furthered by mutual exchange of communication. Approaching care/client as a job, doing things without client input, and doing things your way and efficiently are not necessarily therapeutic, nor do they initiate communication.

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

Which intervention is most appropriate for a client newly diagnosed with diabetes and a nursing diagnosis of Deficient Knowledge?

Teach the client how to administer insulin. explanation: The plan of care should be individualized and specify client outcomes to resolve problems identified in the nursing diagnosis. Because this client has a deficient knowledge of the diagnosed medical condition of diabetes, the nurse needs to educate the client about insulin administration to address the problem identified in the nursing diagnosis. Administering insulin, monitoring blood glucose level, and monitoring symptoms of hypoglycemia and hyperglycemia are all nursing measures used to treat the client and do not directly impact the client's knowledge deficit.

The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client's right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use?

Trial-and-error problem solving explanation: The nurse is using trial-and-error problem solving. This type of problem solving involves testing any number of solutions until one that works for the problem is found. In this situation, the nurse attempts to obtain a blood pressure reading on three extremities before finally achieving success on the right leg; this required the nurse to test a number of locations. Intuitive thinking is a feeling (a sense) that doesn't use rational processes such as facts and data. Scientific problem solving is based on the scientific model. Critical thinking is the objective analysis of facts to form a judgment.

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:

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

The nurse formulates client outcomes based on the understanding that the outcomes should be:

measurable. explanation: The nurse should keep in mind that client outcomes should be measurable, realistic, time bound, and specific to the client. The outcomes are not general, but are specific to the client based on the individual client's problems. The outcomes are realistic and measurable, not abstract. The outcome establishes a definite time frame for achievement.

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. explanation: 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).

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. explanation: The nursing process requires blended skills and critical thinking. Critical thinkers think systematically about the nursing process and apply it for the individual client. Communication is important but not sufficient to meet client needs, and scientific problem solving is used in the laboratory setting, not nursing.