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Chapter 5
Nursing process and critical thinking
| Question | Answer |
|---|---|
| Following the gathering of subjective and objective data, performing a health history and a physical assessment, the nurse sets up a plan of care. What is the first step to identify the problem? | Nursing diagnosis |
| A patient is admitted to the hospital with a sacral wound that has a foul odor, purulent drainage, and necrotic tissue in the center. It measures 4 cm in circumference by 2 cm deep. What is the most appropriate nursing diagnosis? | Impaired skin integrity |
| The nurse reads the order: “Ambulate the patient three times a day at 0900, 1400, 1900 as tolerated” and identifies this as what part of the nursing process? | Nurse-prescribed intervention |
| Considering Maslow’s hierarchy of needs, what would be the highest priority nursing diagnosis? | Imbalanced nutrition |
| A patient has returned from surgery and has a history of smoking. The physician has orders for the use of incentive spirometry (IS) every 2 hours. The patient asks why he has to do IS so often. The nurse teaches the patient about the importance of breathi | implementation of a nursing intervention |
| What is the role of the licensed practical nurse in writing a nursing diagnosis? | To assist with the determination of an accurate nursing diagnosis |
| Nursing process consists of six phases... | Assessment diagnosis outcome identification planning implementation evaluation |
| What are some problems associated with electronic (or computerized) charting? | Security Correct Expense of training staff New terminology |
| When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered? | Logging off |
| The father of an American Indian has just died. What should the nurse do immediately after death? | Ask about providing help with the death ceremony |
| What is the term used to describe cultures in which women make decisions about health care and provide the care and discipline to the children? | Matriarchal |
| What should the nurse be sure to do when documenting in a patient’s chart? | Chart consecutively |
| What is an appropriate outcome statement for a patient with a nursing diagnosis of ineffective airway clearance related to thick secretions? | The patient will increase intake to 1000 mL daily to liquefy secretions. |
| What makes home health care documentation unique? | Different health care providers need access. |
| What does documentation of type of care, time of care, and signature of the person prove? | Interventions were implemented to meet the patient’s needs. |
| When documenting an incident in the nurse’s notes, what should the nurse include? | Description of injury, including diagrams of injury placement Date, time, and location of incident Name of physician and family members notified Chronologic order of events of the incident |
| Why is documentation especially significant in managed care? | Institutions are reimbursed only for patient care that is documented. |
| What is the primary purpose of nursing orders? | To provide direction for all caregivers |
| What are the two primary methods used to collect data? | Interview and physical examination |
| The nurse is caring for a Mexican American patient who is in labor. How can this nurse best demonstrate cultural sensitivity? | Encouraging female family members to be present for the delivery |
| What is the documentation format that uses the acronym SOAPE? | Problem-oriented |
| Which health belief system includes a belief of a supernatural force exerting influence to cause health or illness? | Folk |
| What is the basis for designing and selecting nursing interventions to meet patient needs? | Nursing diagnosis |
| nurse writes two nursing diagnoses: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses? | The second diagnosis reflects a problem that does not yet exist. |
| What is a fixed concept of how all members of an ethnic group act or think? | Ethnic stereotypes |
| What documentation reflects implementation? | Patient was ambulated for 15 minutes after lunch.” |
| What assists the nurse in the identification of nursing diagnoses? | Data clustering |
| A nurse is formulating a nursing diagnosis. What is an example of an appropriately written nursing diagnosis? | Risk for impaired skin integrity related to physical immobilization |
| The nurse from New York City is caring for a patient from Atlanta, Georgia. What difference between the nurse and patient may cause them to experience difficulty in communicating? | Subculture |
| What is a nursing diagnosis considered when a problem is suspected but data to support it are lacking? | A possible nursing diagnosis |
| What organized approach might the nurse use when performing a complete physical examination? | A head-to-toe assessment |
| What best defines the nursing process? | A framework for the organization of individualized nursing care. |
| What is the process used to appraise the practice of an individual nurse known as? | Peer review |
| Documentation is necessary for the evaluation of patient care. Of which phase of the nursing process is this an integral part? | Implementation |
| The nurse charts only additional treatments done, changes in patient condition, and new concerns. What is this system of documentation? | CBE |
| What does the nurse use as a basis for documentation in focus charting? | Nursing diagnoses |
| From where are the “risk for” nursing diagnoses identified? | The assessment |
| During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data? | The patient complains of generalized discomfort. |
| A nurse is American-born and works in a large hospital with patients from many cultures. What must this nurse develop to provide the best care? | Cultural competence |
| All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment? | 53-year-old admitted with a perforated ulcer |
| The nurse is preparing an Orthodox Jewish patient’s tray during Passover. What intervention is appropriate for this patient? | Encourage time for prayer |
| The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation? | A risk factor |
| A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred? | Variance |
| When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process? | planning |
| What is the term for a generalization about a form of behavior, an individual, or a group? | Stereotype |
| What is the nurse required to do to adhere to the concept of confidentiality for the patient’s medical record? | Have a clinical reason for reading the record |
| What is classified as information provided by the family when a patient is unable to provide data during assessment? | Secondary |
| What are categories of inadequate documentation that may lead to a malpractice claim? | Incorrectly recording the time of an event Failing to record verbal orders Charting events in advance Documenting an incorrect date |
| The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type. This is known as a: | critical pathway |
| What is the system that classifies patients by age, diagnosis, and surgical procedure and produces 300 different categories used for predicting the use of hospital resources? | Diagnosis-related groups |
| Who is the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis? | RN |
| What is an example of an appropriate nursing diagnosis? | Impaired skin integrity |
Created by:
kpriest