(PrepU) Chapter 3: Critical Thinking, Ethical Decision Making, and the Nursing Process
A client, 50 years old, is admitted for treatment of a gastric tumor. The client asks the nurse, "Do you think I have cancer?" Which response by the nurse would be most therapeutic?
"You sound concerned about what the physicians will tell you." Reflection is a therapeutic communication tool that validates the nurse's understanding of what the client is saying and signifies empathy, interest, and respect for the client.
Which ethical principle is related to the duty to do good?
Beneficence Beneficence is the duty to do good to benefit others and the active promotion of benevolent acts. Autonomy refers to self-rule. Confidentiality related to the concept of privacy. Nonmaleficence is the duty not to inflict harm as well as to prevent and remove harm.
Which type of law protects each person's freedom and property rights?
Civil law Criminal law concerns offenses that violate the public's welfare. Statutory law is law that any local, state, or federal legislative body enacts. Civil law applies to disputes that arise between individual citizens. Administrative law means that regulatory agencies enforce the rules and regulations that concern health, welfare, and safety of federal and state citizens.
The LPN is collaborating with the RN in developing a plan of care for a new client. Which description of nursing roles best describes the LPN's contribution to the plan?
Data gathering, identification of client strengths, and assurance of client safety during the assessment phase Establishment of priorities, identification of problems and risks, and delegation and management of client care are all roles of the registered nurse during the nursing process. Data gathering, identification of client strengths, performance of assessments and assurance of client safety are role of the LPN when using the nursing process to develop the client plan of care.
Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Which of the following describes interpretation?
Determine the significance of data that are gathered. Analysis is used to identify patient problems indicated by data. Interpretation is used to determine the significance of data that are gathered. Inference is used by the nurse to draw conclusions. Explanation is the justification of actions or interventions used to address patient problems and to help a patient move toward desired outcomes.
Which term is defined as a formal systematic study of moral beliefs?
Ethics Ethics is the formal, systematic study of moral beliefs. Veracity is the obligation to tell the truth and not to lie or deceive others. Fidelity is keeping promises. Morality is the adherence to informal personal values.
A client reports postoperative pain near the incision site on his abdomen. He describes the pain as constantly burning and rates it at an 8/10 using the pain scale. The nurse administers morphine sulfate 2 mg IVP as ordered. Ten minutes later the nurse documents that the client now rates his pain at a 3/10 using the pain scale. The nurse's documentation is an example of which part of the nursing process?
Evaluation Evaluation, the final step of the nursing process, allows the nurse to determine the client's response to the nursing interventions and the extent to which the objectives have been achieved. The other answers are incorrect because they are not the correct phase of the nursing process.
What statement does the nurse determine is a medical diagnosis rather than a nursing diagnosis?
Fever of unknown origin It is important to remember that nursing diagnoses are not medical diagnoses; they are not medical treatments prescribed by the physician, and they are not diagnostic studies. Rather, they are succinct statements in terms of specific patient problems that guide nurses in the development of the plan of nursing care. Fever of unknown origin is a medical diagnosis. The rest are nursing diagnoses.
A client with HIV is visiting the health care center for a regular checkup. The client's symptoms indicate multiorgan infections, and the client reports extreme weakness and feeling depressed most of the time, as friends and colleagues have distanced themselves from the client. Which are the primary areas of concern for the nurse attending the client? Select all that apply.
Instruct the patient to take frequent rest periods. Refer patient to seek psychosocial counseling. Provide patient education related to multiorgan infections. Independent HIV nursing management involves managing the client's psychosocial and educational needs. Diagnosis of opportunistic infections and medication prescription based on viral load are areas of interdependent concerns in disease management.
Which of the following is a true statement about critical thinking according to Alfaro-LeFevre (2006)?
It is guided by professional standards and codes of ethics. Critical thinking is guided by professional standards and codes of ethics. It is based on principles of the nursing process and scientific methods. Critical thinking makes judgments based on evidence rather than conjecture. It considers client, family, and community needs.
Which of the following is a true statement about critical thinking according to Alfaro-LeFevre (2010)?
It is guided by professional standards and codes of ethics. Critical thinking is guided by professional standards and codes of ethics. It is based on principles of the nursing process and scientific methods. Critical thinking makes judgments based on evidence rather than conjecture. It considers client, family, and community needs.
The nurse is to administer a potassium supplement to the client. The nurse does not check the potassium level prior to administering the medication and later finds that the potassium level was at a critical high. What principle has this nurse violated?
Nonmaleficence Nonmaleficence is the duty to do no harm to the client. For instance, if a nurse fails to check an order for an unusually high dose of insulin and administers it, he or she has violated the principle of nonmaleficence. Beneficence is the duty to do good for the clients assigned to the nurse's care. The nurse has a duty to remove wrist restraints whenever possible (removing a harm) and to help the client regain independence (promoting and doing good). Fidelity is the duty to maintain commitments of professional obligations and responsibilities. Autonomy refers to a client's right to self-determination or the freedom to make choices without opposition.
Telling the truth (veracity) is one of the basic principles of North American culture. Three ethical dilemmas in clinical practice can directly conflict with this principle. Choose the three from the list below.
Not revealing a diagnosis to a client Revealing a diagnosis to people other than the client with the diagnosis Using placebos Three ethical dilemmas in clinical practice that can directly conflict with the principle of veracity are using placebos (nonactive substances used for treatment), not revealing a diagnosis to a client, and revealing a diagnosis to people other than the client with the diagnosis. All involve the issue of trust, which is an essential element in the nurse-client relationship. Speaking with any health care professional who is directly involved with the care of the client is acceptable.
The RN develops an outcome standard of "client will ambulate with an assistive device 60 feet with assistance twice a day" for a client who had a hip replacement. What part of the nursing process is involved with this outcome statement?
Planning Establishing the outcomes and actions will help the client achieve the overall goals of care. Assessment is the careful observation and evaluation of a client's health status by the collection of data. Implementation is putting the plan into action, and evaluation is determining the client's responses to the care provided.
Which situation would require the nurse to use critical thinking and decision-making skills in providing genetics-related nursing care?
Providing fertility counseling to a young family with a 2-year-old child with cystic fibrosis Cystic fibrosis is an autosomal recessive genetic disorder. Parents of a child diagnosed with cystic fibrosis have a 50% chance of having another child with cystic fibrosis. Once the nurse assesses the family history, it is appropriate nursing action to for the nurse to make a referral for genetic testing or counseling. Although ADHD may have a genetic component, there is no genetics-related issue in this situation. Lead poisoning is not a genetic disorder. There is no indication that any of the children in the blended family have a genetics-related problem.
Which of the following is the highest level of human need according to Maslow (1968)?
Self-actualization The highest level need is self-actualization. The first level of need is physiological needs. Love and belonging are third-level needs. Esteem and self-esteem are fourth-level needs.
Which intellectual skill is used by nurses when thinking critically?
Supporting evidence with facts Intellectual skills used in critical thinking include supporting evidence with facts, setting priorities through timely decision making, and determining client-specific outcomes. Bias is not used to achieve goals.
In order to establish specific and realistic outcomes so that the client does not become frustrated in trying to achieve them, who should be involved in establishing these outcomes?
The client and family The nurse includes the client and family in establishing outcomes. Outcomes are specific and realistic, so the client can attain them and not become frustrated, and measurable, so the nurse can reliably determine to what extent the client is meeting the goals. The physician, CNA, and case management do not play a role in the development of nursing outcomes.
A newly admitted long-term care client refuses to attend afternoon group activities or social events offered by the facility. According to Maslow's theories on human needs, what is the reason the client refuses to participate in activities?
The client likes to go to have a nap in afternoon and go to bed early in the evening. According to Maslow, the client would need to be sure that basic physiologic and safety and security needs were being met before becoming interested in meeting love and belonging (social) needs. The client needs to have physical needs met like food, sleep, and bowel elimination before requiring increased self-esteem through social activities.
A nurse chooses a quiet, private area to conduct an end-of-shift report to the oncoming nurse. Following this procedure is necessary because of what ethical problem in nursing?
The right of confidentiality is essential to protect each client's private information. Confidentiality is essential to protect the rights of clients. The Health Insurance Portability and Accountability Act (HIPPA) is federal legislation to protect client privacy. Violation of this act could result in criminal or civil litigation. Logging off the computer ensures no one readily has access to client information.
Which of the following is a true statement about expected outcomes?
They are documented as measurable goals. Outcomes are specific and realistic so the client can attain them and not become frustrated, and they are measurable so the nurse can reliably determine the extent to which the client is meeting the goals. They are developed with the client, family, and other healthcare providers when possible. There is a time estimate for achievement.
An advanced directive in which one person identifies another person to make health care decisions on his or her behalf is known as
a durable power of attorney for health care. A durable power of attorney for health care is a type of advance directive in which one person identifies another person to make health care decisions on his or her behalf. Living wills are limited to situations in which the client's medical condition is deemed terminal. A DNR order is an order to have no resuscitative action taken if the client experiences cardiac arrest. Hospice is a type of palliative care for clients with terminal diagnoses.
The nurse is prioritizing a client's care plan based on Maslow's hierarchy of needs. What is an example of the nurse's first priority action?
administering pain medication to a client in acute pain Maslow's hierarchy of needs provides one framework for prioritizing problems, with importance being given first to physical needs. Once those basic needs are met, higher-level needs can be addressed.
An ER nurse must quickly assess two clients who were in a car accident and determine whose needs take priority. In this situation, critical thinking allows the nurse to:
consider all factors, interpret the information, and make decisions relevant to each client's care. Nurses use critical thinking skills in all practice settings. Nurses continually assess their clients' needs and frequently confront situations that require multiple interventions. Developing good critical thinking skills will make nurses more efficient and effective at resolving these situations.
The nurse is developing a client's care plan. What activity best exemplifies the assessment phase of the nursing process?
determines the client has a pulse rate of 88 bpm The assessment phase of the nursing process includes a health history and physical examination. The pulse rate is obtained during a physical assessment. The remaining options are not data obtained during the assessment phase, but steps in the implementation phase of the nursing process.
Which type of nursing diagnosis is a clinical judgment of a client's motivation and behavior to increase his or her well-being?
health promotion The health promotion diagnosis is a judgment of a client's motivation and behavior to increase well-being and enhance health-seeking behaviors. The risk diagnosis identifies potential problems for which the client is at risk. The syndrome diagnosis describes specific diagnoses that occur as a group. The actual diagnosis identifies an existing problem such as Urinary Retention or Anxiety.
The nurse is developing a care plan. At which step of the nursing process will the nurse order the primary interventions to achieve a goal?
planning Nurses will add interventions during the planning stage of the nursing process. Assessment data are gathered through the health history and the physical assessment. Evaluation, the final step of the nursing process, allows the nurse to determine the patient's response to the nursing interventions and the extent to which the objectives have been achieved. Collaborative problems pertain to potential problems or complications that are medical in origin and require collaborative interventions with the health care provider and other members of the health care team.
A longterm care facility's newest client refuses to attend group activities or social events offered by the facility. Which level of Maslow's hierarchy do social events address?
third: love and belonging needs Group activities and social events address love and belonging needs, which is the third level of Maslow's hierarchy.
A nurse saw a coworker steal drugs from a locked cabinet. The supervisor notices the missing drugs and has a good idea who is responsible for the theft. The supervisor asks if the nurse saw anything out of the ordinary. Which professional value reflects a nurse's duty to tell the truth?
veracity Veracity is the nurse's duty to tell the truth in all professional situations. Autonomy refers to a client's right to self-determination. Beneficence is the duty to do good for the clients assigned to the nurse's care. Nonmaleficence is the duty to do no harm to the client.
The following nursing diagnoses are formulated with a client: constipation, acute pain, and caregiver role strain. During the planning phase of the nursing process, the nurse will prioritize the diagnoses in what order?
Acute pain, constipation, caregiver role strain Using critical thinking skills involves a sound knowledge base that leads to the formulation of outcome-oriented activities and identification of client needs. Critical thinking enables accurate prioritization of care. In this case, easing the client's pain is the most important priority, followed by alleviating the constipation, and then addressing the caregiver issues.
Which of the following should the nurse do if a client is being discharged before mastering a complicated dressing change?
Advocate for an additional day in the hospital. Advocacy safeguards clients' rights and supports their interests. If a client is to be discharged before mastering a complicated dressing change, the nurse advocates for an additional day in the hospital or home health visits. A threat to restrain the client's hands constitutes an assault. In case of emergency, healthcare providers can infer consent.
The nurse is caring for a combative and confused client with a fractured hip who is trying to get out of bed. What actions are appropriate for the nurse to take? Choose all that apply.
Ask a family member to sit with the client. Obtain a physician's order to restrain the client. It is mandatory in most settings to have a physician's order before restraining a client. Before restraints are used, other strategies, such as asking family members to sit with the client or using a specially trained sitter, should be tried. The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) and the Centers for Medicare and Medicaid Services (CMS) have designated standards for the use of restraints. A client should never be left alone while the nurse summons assistance. All staff members require annual instruction on the use of restraints, and the nurse should be familiar with the facility's policy. This makes all other answers incorrect.
The nurse is administering a medication to a client for the treatment of his constipation. The client states that he prefers not to take the medication today. The nurse respects the client's right and informs him if he needs it later, just let the nurse know. What professional value is the nurse displaying?
Autonomy Autonomy refers to a client's right to self-determination or the freedom to make choices without opposition. Nonmaleficence is the duty to do no harm to the client. If a nurse fails to check an order for an unusually high dose of insulin and administers it, he or she has violated the principle of nonmaleficence. Beneficence is the duty to do good for the clients assigned to the nurse's care. The nurse has a duty to remove wrist restraints whenever possible (removing a harm) and to help the client regain independence (promoting and doing good). Fidelity is the duty to maintain commitments of professional obligations and responsibilities.
The use of patient restraints limits which ethical principle?
Autonomy It is important to weigh carefully the risk of limiting a client's autonomy and increasing the risk of injury by using restraints against the risk of not using restraints. Beneficence refers to an act of goodness, justice in nursing often refers to bioethics and means giving to others what is due, finally trust is building a relationship based on reliability and truths. The patient's autonomy is limited with the use of restraints.
The nurse prepares to administer medication to the patient. The patient states, "I would prefer not to take that medication until I speak with my physician." The nurse honors the patient's desire to make decisions, following which common ethical principle?
Autonomy This word autonomy is derived from the Greek words autos ("self") and nomos ("rule" or "law") and therefore refers to self-rule. In contemporary discourse, it has broad meanings, including individual rights, privacy, and choice. The principle of autonomy entails the right of patients to receive adequate and accurate information so that they have the ability to make a choice free from external constraints. Beneficence is the duty to do good and the active promotion of benevolent acts (e.g., goodness, kindness, charity). It also entails taking positive action to prevent patients from harming themselves or others, including society as a whole. Fidelity is faithfulness. Paternalism is doing tasks for a person that the person can do for his or herself.
The nurse is caring for a terminally ill client in the intensive care unit that is on life support measures. The family members are opposed in their decision to take the client off of life support. What option does the nurse discuss with the nurse manager?
Contact the ethics committee for their input. The ethics committee may be called on to act as an advocate for clients who no longer are mentally capable of making their own decisions. Ethics committees are a valuable resource for reviewing difficult cases and helping ensure a careful and unbiased decision. The nurse is not practicing within the scope of practice by taking the client off of life support. The nurse does not mandate to the health care provider decisions that should be made. It is nontherapeutic for the nurse to ask the family to go out and make a decision.
Analyzing information for patterns, maintaining a flexible attitude, and making decisions reflecting creativity are all what type of components necessary for nurses?
Critical thinking Critical thinking requires going beyond basic problem-solving and results in comprehensive plans of care.
The nurse obtains a client's oral temperature reading of 36.8°C. How should the nurse proceed?
Document the client's temperature result as obtained. The normal oral temperature can vary from 36.6°C to 37.3°C. There is a normal variation of 1 or 2 degrees in body temperature throughout the day.
Which element is involved in the planning phase of the nursing process?
Identify measurable outcomes The planning step of the nursing process involves identifying measurable outcomes, selecting nursing interventions, and documenting the planning steps. The implementation step involves carrying out nursing orders. The diagnosis step involves identifying collaborative problems. Completing a health history is done in the assessment step.
Which of the following is a true statement about a living will?
It states the client's wishes regarding healthcare if terminally ill. A living will states the client's wishes regarding healthcare if terminally ill. It does not specify information regarding nontreatment only, it is not a legal consent, and it is not a type of financial agreement.
The nurse needs to perform an admission assessment for a client who does not speak the same language as the nurse. The client's wife is fluent in both the nurse's and the client's languages. When completing the physical assessment is critical in planning patient care, how should the nurse proceed?
Obtain a translator to assist with interpretation during admission assessment. Translation services should be provided for non-English-speaking patients. Asking the patient's wife violates the patient's confidentiality. Physical findings alone are not sufficient; the nurse must understand the patient's interpretation of the physical findings to provide culturally competent nursing care. Completion of the admission assessment in privacy and documenting the language barrier does not address the need for interpretation of the patient's history, perception, and description of assessment findings.
Which step of the nursing process involves setting priorities and determining specific nursing interventions?
Planning Planning involves setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care. Assessment is careful observation and evaluation of a client's health status. 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. Evaluation is assessment and review of the quality and suitability of the care given and the client's responses to that care.
A client has been a resident of a long-term care facility for several years. The client's condition has deteriorated to the point that the client is now unable to eat. The physician has recommended surgical implantation of a feeding tube. The client's family has a legal document outlining the client's wishes in regard to measures such as this. What is this document?
advance directive An advance directive provides the means for clients to communicate their wishes regarding life-sustaining treatment and other medical care, so that their significant others will know what decisions the clients desire. The two types of advance directives are the living will and durable power of attorney for healthcare. Informed consent is voluntary permission granted by a client or the client's healthcare proxy for a treatment, procedure, or surgery to be performed. A form is used to obtain this consent. A durable power of attorney is a legal document that appoints a person to act as an agent for another person. A DPOA for healthcare appoints a person to make medical decisions for a client who is incapacitated and unable to make decisions for himself or herself. Do-not-resuscitate (DNR) orders involve a written medical order for end-of-life instructions. If a DNR order is written, the client wishes to have no resuscitative action taken if he or she experiences a cardiac arrest.
Prioritizing client care is an ongoing process within the art of nursing. Abraham Maslow proposed five levels of need and grouped them according to significance. Which client need is of primary importance?
breathing easily The first-level needs, sometimes called baseline survival needs, have the highest priority. These activities, such as eating, breathing, and drinking, sustain life. Maslow believed humans could not or would not seek to fulfill higher level needs until basic physiologic needs were met. Safety and security are a secondary need, not primary. Needs related to getting along with others are important, but they are not primary needs. Needs related to feeling connected to the larger society are important, but they are not primary needs.
The fifth step of the nursing process is evaluation. As part of this step, the nurse:
compares actual client outcomes to the expected outcomes. Evaluation consists of assessment and review of the quality and suitability of care given and the client's responses to that care. During evaluation, nurses compare the actual outcomes to the expected outcomes. The other actions are related to planning, evaluation, and implementation.
The nurse is attending a client with chronic renal failure. The client is experiencing a loss of appetite and reports feeling like everyday situations have become more stressful. The client reports feeling disappointed and frustrated with the condition, and says the family is not getting any help. What is the most important nursing intervention that the nurse needs to carry out at this point?
coordinate with resources for client support Promotion of psychological comfort is one of the most important aspects of the care of a client with chronic renal failure. Coordination of resources for client support is an appropriate nursing intervention in this situation. Scheduling a family meeting is a start, but more resources for the client may be needed. Nutritional counseling and administration of immunosuppressant drugs are medical management tasks.
The physician has ordered cimetidine for a client with gastric ulcers, and the nurse administers the first dose. The nurse's actions are noted in the medical record. This notation is an example of which aspect of implementing the plan of care?
documentation An important element of implementation is documentation. By law, nurses must document all nursing actions, observations, and client responses in a permanent record.
Several times, family members have asked a nurse to share personal prescriptions when they were in need of pain medication or antibiotics. Which type of rules or standards should govern the nurse's moral decision?
ethics Although all of the options may affect the decision, moral decisions are guided by ethics (moral principles and values that guide the behavior of honorable people). Ethical standards dictate the rightness or wrongness of human behavior. Laws are written rules for conduct and actions. They are binding for all citizens and ensure the protection of rights.
Patient health education provided by the nurse
is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts. Teaching, as a function of nursing, is also included in all state nurse practice acts. Health education is a primary responsibility of the nursing profession. Health education by the nurse focuses on promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.
Which type of nursing diagnosis identifies an existing condition that the client is experiencing?
problem-focused The problem-focused diagnosis identifies an existing problem such as Urinary Retention or Anxiety. The health promotion diagnosis is a judgment of a client's motivation and behavior to increase well-being. The risk diagnosis identifies potential problems for which the client is at risk. The syndrome diagnosis describes specific diagnoses that occur as a group.
Which type of nursing diagnosis identifies potential problems that may arise due to the client's disease, condition, or situation?
risk Risk nursing diagnoses identify potential problems and use the stem "risk for" as in Risk for Impaired Skin Integrity related to inactivity. The actual diagnosis identifies an existing problem such as Urinary Retention or Anxiety. The health promotion diagnosis is a judgment of a client's motivation and behavior to increase well-being. The syndrome diagnosis describes specific diagnoses that occur as a group.
