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Concepts II: Ch. 4
The Nursing Process: Critical Thinking and Decision Making
| Question/Term | Answer/Definition |
|---|---|
| Question: The nurse prepares a handout about the nursing process for an orientation class of new colleagues. Which should the nurse use to explain this process? | Answer: Decision-making framework used by nurses to determine the needs of clients |
| Question: When preparing a plan of care, the nurse uses skillful reasoning and logical thought to determine the merits of an action. Which action is the nurse performing? | Answer: Critical thinking |
| Question: While caring for a newly admitted client, the RN gathers information by interviewing the client to obtain a health history and reviewing the results of laboratory and diagnostic tests. Which step in the nursing process did this nurse complete? | Answer: Assessment |
| Question: The nurse is performing a shift assessment on a client. Which information should the nurse identify as objective data? | Answer: The client demonstrates facial grimacing |
| Question: The LPN/LVN assists the RN in completing an admission history with a confused client. Which information should be identified as secondary information? | Answer: The client’s spouse reports experiencing marital issues |
| Question: While performing a shift assessment, the nurse visually examines a client’s body for rashes and breaks in the skin, and looks for normal appearance of eyes, ears, nose, mouth, limbs, and genitals. Which assessment technique is nurse using? | Answer: Inspection |
| Question: The nurse reviews problems identified for a client. Which problem should the nurse list as a priority? | Answer: Has irregular heart rhythm |
| Question: The nurse meets with the physical and occupational therapist to plan care for a client with nerve damage caused by a back injury. Which type of intervention will be listed on the plan of care? | Answer: Collaborative |
| Question: The nurse is planning interventions for a client experiencing nausea and vomiting after receiving chemotherapy. Which intervention is individualized for this client? | Answer: Provide 8 ounces enriched milkshake mid-morning and mid-afternoon |
| Question: A client has a critical pathway to be used for providing care. Which should the nurse keep in mind when following this plan of care? | Answer: Care is based upon the day of hospitalization |
| Question: The nurse reviews outcome statements with a new colleague. Which information about outcome statements should the new nurse identify as being appropriate? | Answer: 1. “An outcome statement should be a realistic, specific action.” 2. “An outcome statement is an action that is measurable and can be evaluated.” 3. “An outcome statement has a definite time frame for completion of the action.” |
| Question: The nurse reviews a care plan prepared for a client. Which are indirect nursing interventions in this plan of care? | Answer: 1. Documenting a client’s bath 2. Informing the physician about a client’s pain |
| Question : The nurse is preparing to care for a client. Which action should be completed before implementing any identified interventions? | Answer: 1. Maintain privacy 2. Explain the procedure 3. Gather equipment and supplies 4. Check the health-care provider’s order |
| Critical Thinking | Skillful reasoning and logical thought to determine the merits of a belief or action |
| Validating obtained information: | Ensuring the correctness of the information they obtain |
| Thinking purposefully | Using reasoning and logical thought, to determine whether their actions are appropriate for the optimal care of the patient |
| The Nursing Process | ‒ A.D.P.I.E. 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation |
| The Nursing Process: Assessment | ‒ Interviewing ‒ Physical assessment |
| The Nursing Process: Diagnosis | ‒ Analysis of the assessment information gathered |
| The Nursing Process: Planning | ‒ Determining priorities |
| The Nursing Process: Implementation | ‒ Interventions |
| The Nursing Process: Evaluation | ‒ Reflect on interventions |
| Physical Assessment | 1. Auscultation 2. Inspection 3. Palpation 4. Percussion |
| Maslow’s hierarchy of human needs | 1. Physiological 2. Safety & security 3. Love & belonging 4. Self-esteem 5. Cognitive 6. Aesthetic 7. Self actualization 8. Transcendence |
| Outcome statements contain: | 1. A realistic, specific action to be taken by the patient 2. An action that the patient is willing and able to perform 3. An action that is measurable 4. A definite time frame for the action to be accomplished |
| Question: What does NANDA stand for? | Answer: North American Nursing Diagnosis Association |
| Objective data | Things that you can observe through your senses of hearing, sight, smell, and touch |
| Subjective data | Information that comes from feelings of the patient |
| Direct care | Performed when the nurse interacts directly with the patient (ex: Bathing, teaching, listening, administering medications) |
| Indirect care | Performed when the nurse provides assistance in a setting other than with the patient (ex: Documenting care, participating in care conferences, talking with the health-care provider, etc) |
| Nursing Interventions Classification (NIC) | ‒ Direct care ‒ Indirect care ‒ Dependent care (ex: administering meds) ‒ Independent care (ex: baths, massage) ‒ Collaborative care (RN, PT & RT working together on a patient) ‒ Individualized care |
| Question: What type of nursing intervention requires a health-care provider’s orders before they can be performed? | Answer: Dependent |
| Types of Nursing Care Plans | ‒ Computerized ‒ Standardized ‒ Multidisciplinary (PT, OT) ‒ Critical pathway (time framed) ‒ Student care plans |
| Question: Which type of nursing care plan provides daily nursing interventions that change as the patient improves? | Answer: Critical pathway |
| Critical pathway | They are based on the progression for each day the patient is in the hospital |
| Concept Maps (Mind maps) | Help to see relationships between nursing diagnoses and assessment data; Help to organize and plan nursing care |
| Clinical judgment | Taking critical thinking and turning it into nursing actions |
| Steps of clinical judgment | 1. Recognize cues and analyze them 2. Formulate a hypothesis, or possible explanation of what is happening 3. Take action by priority 4. Evaluate the effectiveness of your actions |
| Question: The nurse reviews a care plan prepared for a client. Which are indirect nursing interventions in this plan of care? | Answer: ‒ Documenting a client’s bath ‒ Informing the physician about a client’s pain |
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