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NURS 201-Chapter 13
Health Competencies, Clinical Reasoning, & Processes of Person-Centered Care
| Question | Answer |
|---|---|
| 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 -Statement that focuses on the client, is realistic, and is measurable |
| What is 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 |
| Which statement is true of the nursing process? | Scientific problem solving can occur within the nursing process |
| 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 -collects data that determine the need for nursing care |
| 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 -need for more information |
| A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client’s room, the client 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 -Objective finding = client talking out loud when no one else is in there -Subjective finding = client reporting hearing voices in the head |
| Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing? | Evidence-based practice -Makes judgments based on evidence rather than conjecture (speculation) |
| Which statement regarding critical thinking in nursing is true? | It is a systematic way of thinking -Involves purposeful, outcome-directed thinking |
| 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 -Planning = determining the correct length of the NG tube to insert -Implementing = actual insertion of the NG tube |
| The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse? | Involving the client with all the steps of the process in care development -Because the plan of care should be client-centered, the client should be directly involved with all phases of the creation of the care plan |
| What is an example of objective data? | Pain report |
| What is an example of subjective data? | Includes information from the client, such as reports of pain or anxiety |
| What is intervention? | The action to be completed based on the nursing diagnosis and intended outcome (e.g., administering a prescribed analgesic or documentation of medication) |
| What is a nursing diagnosis? | A clinical judgment about an individual, family, or community experience/response to an actual or potential health problem |
| When is scientific problem solving used? | In the laboratory setting, not nursing |
| What is an example of example of evaluation through assessment? | Evaluating the temperature of a client given medication for a fever |
| Accuracy | Reflected in questions about the information being true |
| Precision | Reflected by questions asking for more details or specifics |
| Relevance | Reflected by questions related to how something connects to the issue |
| Assessment | -The collection of data that enables the nurse to make judgments about the level of care the client needs -Should be documented accurately, completely, concisely, factually, and in a timely manner |
| 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 -Recognizes the existence of cues and conducts a focused data collection |
| Which statement best conveys the role of intuition in nurses' problem solving? | Intuition can be a clinically useful adjunct to logical problem solving |
| Nurse is caring for a client with an identified nursing concern of fluid volume deficiency. Nurse implements the plan of care and on evaluation finds that the client continues to exhibit symptoms of fluid volume deficiency. What should the nurse do next? | Modify the plan of care and interventions to meet the client’s needs |
| Nurse cares for underweight female diagnosed with a new food allergy to wheat, rye, and oats and with the nurse identifies the nursing concern of altered nutrition that is less the required. What is the most appropriate intervention for this client? | Administer a high-calorie diet, excluding wheat, rye, and oats |
| Nurse develops plan of care for client with 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 |
| Which action is performed in the implementation step in the nursing process? | Documenting the nursing care and client responses |
| Which is a characteristic of person-centered care? | It is a framework for providing 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 |
| A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to: | Complete the postoperative assessment -Assessment is the first priority, which would include breathing, level of consciousness, vital signs, dressings, intravenous sites, and pain level |
| Diagnosis | Nurse clusters cues, interprets the clusters, and validates the diagnoses for accuracy |
| Planning | Preparing a client plan of care, which directs the activities of the nursing staff in the provision of care -Involves selecting nursing interventions, documenting the plan of care, and identifying measurable outcomes |
| Implementation | The action phase of the nursing process -Involves documenting the nursing care and client responses |
| 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 next nursing action? | Assess the client’s back visually -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 concern |
| A nurse has completed a client assessment and is preparing to identify appropriate nursing concerns. Which area(s) will the nurse likely address in the nursing concern? | -altered mobility -altered nutrition -ineffective coping |
| Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes? | Reflection |
| The nurse administers pain medication to a postoperative client. Which nursing intervention will assist with the client’s unrelieved pain? | Repositioning the client -It is nonpharmacologic and does not require a prescription from the health care provider and can assist with pain relief -Administering extra pain medication may only be done with a prescription from the health care provider |
| A nurse has developed a plan of care for an adult client. What nursing function is important when using the identified nursing concerns to guide the care of this client? | Prioritize the nursing concerns |
| The clinical nurse manager is evaluating a new nurse who has been employed for 3 months. What type of knowledge does the manager evaluate that is required for competent clinical reasoning? | -The nurse is committed to the organization's mission and values -The nurse is able to organize and manage time efficiently -The nurse understands nursing and medical terminology |
| 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 -Initially checking blood pressure is an example of assessment -Recognizing BP as an anomaly constitutes diagnosis -Administering the drug itself would be implementation |
| 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 |
| 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 -This is a single, observable, and measurable outcome |
| What type of intervention is the nurse performing when the nurse observes the spouse of a postoperative client performing the client's dressing change? | Supervisory |
| Outcomes | Created to specify a resolution to the identified health problem reflected in the identified nursing concern |
| Breadth | Demonstrated by asking whether there is another way to look at this situation -This question attempts to address other issues that may or may not be impacting the situation |
Created by:
kmeans34
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