PrepU Chapter 2: Critical Thinking in Health Assessment
A quality control nurse is reviewing client satisfaction survey comments. The nurse is most likely to read which positive remark?
"Staff nurses report at the bedside so I can hear the information."
A new order for an antibiotic is received for a client. The nurse reviews the client's electronic medical record. The record states the client has no known allergies. What action should the nurse take?
Ask the client if they have allergies.
A client who underwent abdominal surgery this morning reports feeling weak and dizzy. The nurse also observed a decrease in urine output in the last hour. What action should the nurse take first?
Asses the client
When the nurse clusters the data to make a judgment or statement about the client's condition, this is known as what?
Diagnosis
Essential characteristics for the development of critical thinking skills include all the following except:
Following instructions
The nurse is performing a health assessment on a client. Which of the following would be most important for the nurse to do?
Interpret the information about the client in context
Which of the following would be most important for a nurse when developing critical thinking skills?
Maintenance of an open mind
Which of the following statements is true of nursing diagnoses?
They focus on the responses of clients to health problems and events.
During an initial health history, a client states, "I haven't slept in weeks." The nurse asks, "You are saying that you have not had any sleep in weeks?" What communication technique is the nurse using to obtain accurate subjective data from the client?
rephrasing
After collecting subjective and objective data for the admission database, what is the nurse's next action?
Validate the client's identified problems.
Prior to administering medications, the nurse reviews a client's vital signs. What actual client concern will require collaborative care?
a client reporting a new onset headache and visual changes who has a blood pressure of 170/98 mm Hg (normal range 90-120/60-80 mm Hg)
The nurse has learned that after completing the assessment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do?
analyze the data
The nurse is collecting data from a client. Which of the following best reflects objective data?
appearance
Which statement would demonstrate the correct method for writing an evaluation of client progress after implementing the nursing process?
client ambulated 3/3 times during a planned 8-hour period
Revising the plan as needed occurs in what part of the nursing process?
evaluation
A client who is 2 days postoperative reports pain and requests pain medication. After assessing the client's pain level, the nurse decides to give the client oral oxycodone hydrochloride-acetaminophen instead of intravenous morphine. This nurse is doing which step of the nursing process?
implementation
The nurse is developing goals after completing the assessment of a newly admitted medical client. The nurse would document the goals under which part of the nursing process?
planning
An unlicensed assistive personnel (UAP) reports a low oxygen saturation level of 85% on a client. The nurse enters the room to find the client talking on the phone with a family member, laughing. What is the first action of the nurse?
recheck the client's oxygen saturation
The nurse collects data from a client with a nonproductive cough and labored respirations at a rate of 24/minute. What other data should the nurse collect before formulating an appropriate nursing diagnosis?
status of breath sounds
A hospital nurse has identified a need to improve her critical thinking skills in an effort to improve client care. The nurse should identify which of the following characteristics of critical thinking?
It involves reflections on thoughts before reaching conclusions.
A nursing instructor is describing why data analysis is considered a very difficult step in the nursing process. Which of the following would the instructor identify?
It requires diagnostic reasoning skills.
A nurse has completed data analysis. Which of the following would the nurse identify first as the result?
Nursing diagnosis
The nurse is exhibiting critical thinking in which client care situation?
Performing a focused assessment on a client who is complaining of shortness of breath.
A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client?
Unable to feel his leg
Your client has been directly admitted from the doctor's office. The only paperwork he has brought with him is his admission orders. You are gathering your admission data when ordered lab work is collected. When documenting your history, physical examination, assessment, and plan, what would you write under the heading "Laboratory Data"?
none currently
The nurse's assessment of a client with a decreased level of consciousness reveals that the client is incontinent of urine. During the process of data analysis, the nurse would be justified in identifying what risk for client concern?
risk for altered skin integrity associated with urinary incontinence
An instructor is describing how to arrive at an informed clinical judgment to a group of students. The instructor is accurate when describing that the nurse will cluster supportive and abnormal cues. In which step toward making a clinical judgment will the nurse cluster the cues?
second step
The nurse is caring for a client in the health care provider's office. In reviewing the client's chart, the nurse recognizes the need for providing the client with additional education related to COVID-19 when noting which of the following about the client?
works in the service industry
The nurse is reviewing a client's health history and the results of the most recent physical examination. Which of the following data would the nurse identify as being subjective? Select all that apply.
-"i feel so tired sometimes" -client complains of a headache -"my father died of a heart attack"
A nurse has selected several nursing diagnoses in the process of data analysis for a client with poorly controlled type 1 diabetes. One of these collaborative problems is altered health maintenance due to infrequent blood glucose monitoring as manifested by elevated HgA1C. How would the nurse best validate this diagnosis with the client?
"Would you agree that there's room for improvement in your routines for blood sugar monitoring?"
The nurse collected extensive data during a client assessment and is performing the first step in the process of data analysis. Successful completion of this step requires the nurse to do which of the following?
Differentiate between expected findings and abnormal findings.
A nurse provided dietary counsel for a client who recently immigrated to the United States from Japan. During the initial interview, the client had his eyes lowered and did not make eye contact with the nurse. In analysis of the data, the nurse wrote down the following hunch: "risk for imbalanced nutrition related to client's unwillingness to listen to dietary advice." At the next meeting with the client a month later, however, the nurse was surprised to find that the client had adopted all recommended changes from their initial interview. Which error did the nurse commit in this case?
Overlooking consideration of the clients cultural background
The nurse has completed a comprehensive assessment and physical examination on a 28-year-old client recently admitted to the medical-surgical unit after suffering non-life-threatening injuries in a motor vehicle accident. The nurse identifies possible client concerns after analyzing and making inferences from the abnormal and supportive cues. What is the next best action for the nurse to take?
Validate client concerns with the client.
A nursing student is learning how to use critical thinking in formulating a plan of care. The student understands which of the following to be things needed to demonstrate that the process of thinking critically has begun? (Select all that apply.)
-reserves a final opinion until further collecting data -explores other alternatives before making a decision -uses past knowledge and experience to analyze data
A nurse provides care for a client with an elevated temperature. The client is given the prescribed medication and the nurse checks the client's temperature at repeated intervals. What step of the nursing process is the nurse using to determine if the client has achieved the outcome criteria of the treatment?
Evaluation
A nurse is collecting data on a client's chief complaint, which is a spell of numbness and tingling on her left side. Which of the following questions would be best for eliciting information related to associated factors?
"What other symptoms occurred during the spell?"
The nurse receives a report on a group of clients. What client statement requires further clarification to ensure client safety? Select all that apply.
-"I do not usually take insulin." -"This looks like a new pill." -"I fell at home last month."
The nurse is attempting to understand how the concept of critical thinking relates to how critical thinking is demonstrated in the nursing practice. Which statement indicates a basic understanding of how critical thinking is displayed in the nurse's interaction with clients and colleagues? Select all that apply.
-explores and considers alternatives prior to making a clinical judgment -asks the client for more information when additional understanding is required -validates data and clinical judgments with other experts in the field -uses past knowledge and experience when analyzing data
A client admitted with a small bowel obstruction requires a nasogastric tube to continuous low wall suction. The nurse monitors gastric output of 250 mL at 0800-0900 and 30 mL at 0900- 1000. The nurse understands that drainage should taper and not decrease abruptly within an hour. What is the best action of the nurse?
Assess the nasogastric tube for proper functioning.
A nurse reviews the vital signs of a client: ● 0800: temperature: 99.5° F (37.5° C), heart rate: 85 regular; blood pressure: 110/60; 02 saturation: 95% room air ● 1200: temperature: 99.7° F (37.6° C), heart rate: 88 regular; blood pressure 112/62; 02 saturation: 90% room air ● 1230: temperature: 99.9° F (37.7° C), heart rate 87 regular; blood pressure 115/64; 02 saturation: 88% room air The nurse applies oxygen to the client. What action should the nurse take next?
evaluate outcome
A nurse has completed a comprehensive assessment of a client and has begun the process of data analysis. Data analysis should allow the nurse to produce which direct result?
nursing diagnosis
The nursing student understands that data analysis is referred to as the diagnostic phase because the end result is the identification of which of the following?
nursing diagnosis
A nurse is teaching a client newly diagnosed with diabetes about diet and the exchange list. After several teaching sessions, the client continues to be confused and not sure about what to eat. The nurse's next best action is which of the following?
schedule a dietary consult
A nurse working on a medical-surgical unit in a hospital reviews a client's chart. The client is alert and oriented. No bowel movement has been documented for 5 days. What is the first action of the nurse?
verify the information with the client
A nurse working in a long-term care facility is performing a comprehensive assessment on an 84-year-old male resident. Click to highlight the findings that will require follow-up.
-last bowel movement was charted 7 days ago -No urine output has been charted in the last 24 hours -heart rate 120 beats/min and irregular -oxygen saturations 88% on room air
The result of a nursing assessment is the
Formulation of nursing diagnoses
