Nursing
protection, promotion and optimization or health and abilities, prevention of illness and injury, alleviation of suffering thru the diagnosis and treatment of human response and advocay in the care of individuals, families and communities and populations
Nursing process
systematic method that directs the nurse and patient and includes 5 steps (1) Assessing (2) Diagnosing (3) Outcome identification and planning (4) Implementing (5) Evaluating
Assessing
Collection, validation and communication of patient data
Diagnosing
Analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve
Outcome identification and planning
specification of patient outcomes to prevent, reduce, or resolve the problems identified in the nursing diagnoses and related nursing interventions
Implementing
carrying out the plan of care
Evaluating
measuring the extent to which the patient has acheived the outcomes specified in the plan of care; revising the plan of care if necessary
Trial-and-error problem solving
testing any number of solutions until one is found that works for that particular problem
scientific problem solving
systematic, seven-step problem solving process that involves (1) problem identification (2) data collection (3) hypothesis (4) plan of action (5) hypothesis testing (6) interpretation of results (7) evaluation
Intuitive problem solving
direct understanding of a situation based on a background of experience, knowledge and skill that makes expert decision making possible
decision making
purposeful, goal directed effort applied in a systematic way to make a choice among alternatives
bias in decision making
-placing excess emphasis on 1st data received
-avoiding info contrary to one's opinion
-selecting alternatives to maintain status quo
-being predisposed to a single solution
-stating problem in a way to support one's choices
-making decisions to support p
Failure to consider total situation
-using inaccurate data
-not clearly identifying problems in order of importance
-using unrealistic goals
Impatience
-failing to identify multiple solutions
-incorrectly implementing the decision
-failing to use the appropriate resources
critical thinking
systematic way to form and shape one's thinking
standards for critical thinking
clear, precise, specific, accurate, relevant, plausible, consistant, logical, deep, broad, complete, significant, adequate, fair
critical thinking indicators (CTI) by LeFeure
evidence-based descriptions of behaviors that demonstrate the knowlede, characteristics and skills that promote critical thinking in clinical thinking in practice
concept mapping
instructional strategy that requires learners to identify, graphically display and link key concepts
Annie suspects her roomate Angela suffered date rate and chose not to report the date rape and doesn't seem to be coping well. (1) After taking w/ Annie, you learn that although Angela blurted out that she had been raped when she first came home, since th
Assessing
After analyzing the data, you believe Angeal might be experiencing (2) rape-trauma syndrome: silent reaction.
2. The nursing activity represented as (2) is an example of which step in the nursing process?
Diagnosis
After a conversation with Angela confirms your suspensions and problem identification, you tak with Angela (3) to develop some treatment goals and nursing interventions most likely to yield the outcomes you both seek.
3. The nursing activity represented a
Planning
In your initial meeting with Angela, (4), you encourage her expression of feelings and help her to identify personal coping strategies and strenghs.
4. The nursing activity represented as (4) is an example of which step in the nursing process?
Implementing
You and Angeladecide to meet in 1 week (5) to assess her progress toward achieving targeted outcomes. If She is not making progress, you might need to modify the plan of care.
5. The nursing activity represented as (5) is an example of which step in the n
Evaluating
Which of the following statements about the nursing process is most accurate?
The state board examination for professional nursing practice now use the nursing process rather than medical specialties as an organizing concept.
The nursing process ensures that nurses are patient centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mr, Barclay today?" Are our nursing actions helping her to achieve her goals? H
Interpersonal
An experienced nurse tells you not to bother studying too hard since most clinical reasoning becomes "second nature" and intuitive" once you start practicing. What thinking below should underlie your response?
When intuition is used alone, there are increased risks and fewer benefits. Intuition often moves problem solving forward quickly, but it might result in a lot of trial-and-error approaches.
This text is based upon a notion of blended skills. Simply described, what does this mean?
Nursing works best when each nurse completely uses the intellectual, interpersonal, technical, and ethical/legal skills demanded by each situation.
The best description of critical thinking indicators (CTIs) is which of the following?
Evidence-based descriptions of behavrios that demonstrated the knowledge, characteristics, and skills that promote critical thinking in clinical practice
What step of the nursing process is the nurse performing when analyzing patient data to identify patient strengths and health problems that independent nursing interventions can prevent or resolve?
Diagnosing
A patient who has been admitted to the hospital for the treatment of a gastrointestional bleed requires a transfusion of packed red blood cells. WHich of the following aspects of the nurse's execution of this order demonstrates technical skill?
Starting a new large-gauge intravenous site on the patient and priming the infusion tubing
The patient asks the nurse about side effects of a drug that is newly prescribed. The drug is new on the market, and the nurse is not familiar w/ side effects and responds, "I am not familiar w/ the side effects of this drug, so I will look it up and let
Being intellectually humble
A hospice nurse is meeting w/ parents of a terminally ill child. The nurse listens to concerns and fear the parents are verbalizings as they prepare to allow the child to die at home. What Critical Thinking Indicator characterizes the behavior of the hosp
Emphathic
A student nurse has reconstituted a dose of ampicillin by adding sterile water to the vial that contained the powdered form of the drug. The student has asked her preceptor for the rationale behind this waiting period, but the preceptor is unsure of the r
Intellectual humility
An obstretric nurse has reported to the nurse manager that he observed a colleague taking narcotic drugs from the medication cart and not administering the drugs to the patient. The nurse manager dismisses this information and dose not investigate further
Whistle-blowing
Whistle blowing
employees who report their empolyer's violation of the law to law enforcement agencies
The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill?
Cognitive skill
A hospital patient has an aggressive fungal infection in his right eye that has neccessitated evisceration (removal of the eye). Consequently, the patient requires twice-daily packing and dressing changes to his orbit. Which of the nurse's following actio
Ensuring the patient's privacy during dressing changes and providing an explanation during the procedure
A nurse has come on day shift and is assessing the patient's intravenous set up. The nurse notes that there is a mini-bag of the patient's antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patient's medication admin
Ethical/legal skills
In which of the following situations would the nurse be most justified in implementing trial-and-error problem solving?
The nurse is attempting to landmark an obese patient's apical pulse.
The nursing process is based upon the process of problem solving. What type of problem solving is the nurse using if she attemps to obtain a blood pressure on the patient's right arm, left arm, left leg and then finally the left leg where a blood pressure
Trial-and-error problem solving
Two nurses have disagreed about the role in intuition in nursing practice, with one nurse characterizing it as "hocus-pocus" and the other nurse advocating it as a superior problem-solving strategy. Which of the following statements best conveys the role
Intuition can be a clinically useful adjunct to logical problem solving
The orderly progression of steps of the nursing process is:
assessment, diagnosis, planning, implementation, evaluation,
(ADPIE)
The nurse has entered the room of a newly admitted patient who states she is feeling short of breath. After identifying this complaint asthe patient's problem, what steps should the nurse follow in the process of scientific problem solving?
1. Collect assessment data
2. Formulate a hypothesis
3. Perform hypothesis testing
4. Make a plan for action
5. Evaluate
6. Interpret results
Which of the following statements is true of the nursing process?
Scientific problem solving can occur within the nursing process
Which of the following activities is the clearest example of the evaluation step in the nursing process?
Checking the patient's blood pressure 30 minutes after administering the captopril
The nurse has measured from the tip of the patient's nose to his earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. WHich of the following components of the nursing process has the nurse
Planning: implementing
What components are located at the center of a concept map?
Patient's current and past medical histories
The nurse determines that an appropriate nursing diagnosis for a postoperative patient is Risk for Infection. Which of the following is an appropriate long-term goal consistent with this identified nursing diagnosis?
The patient will remain free of infection after discharge
The nurse is caring for a patient in a critical care unit. The patient's cardiac monitor alarms, and the nurse recognizes the rhythm as atrial flutter. What two skills did the nurse use to interpret this cardiac cardiac rhythm?
Cognitive and technical skills
nurse is educating a pregnant woman in preterm labor on the use of her home monitoring equipment and her medications. What factor could impede the patient's ability to learn?
Anxiety
Select the best description of how the nurse applies the nursing process in caring for patients. The nurse:
uses critical thinking to direct care for the individual patient.
The nurse employs interpersonal skills of communication when caring for and interacting with patients. Which of the following is the best example of establishing a therapeutic nurse-patient relationship?
Respect for the patient and open communication to engage in getting to know the patient.
Which of the following is a true statement regarding critical thinking in nursing?
It is a systemic way of thinking
A patient complains of weakness following his administration of insulin. The nurse decides to assess the patient's blood sugar and prepare a snack in case the blood sugar is low. What action has the nurse implemented?
Clinical reasoning
Which step of the nursing process involves setting long-term goals and short-term expectations?
Planning
Many of the homeless patients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic because it is located in a high-rise building on a university campus. Several of the patients state that the clinic is difficult to find and in
Psychosocial background of patients
When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?
Focus
A nurse is caring for a client diagnosed with arthritis who is experiencing pain that is interfering with her ability to ambulate. The nurse accurately documents which of the following as a nursing diagnosis in the client's records?
Impaired physical mobility related to pain
Which statement related to the evaluation of outcome attainment for a patient is correct?
Collecting data related to outcome attainment requires the nurse to know when to collect the data based upon established time criteria.
The primary purpose for evaluating data about a client's care according to a functional health approach is to
Revise or modify the nursing care plan
During the introductory phase of interviewing for the purpose of obtaining information for the nursing history, the nurse should
Inform the client of the maintenance of confidentiality
When a nurse notices the client is in pain and needs to learn to walk on crutches, which outcome identification is the priority?
Pain management
Which documentation tool will the nurse use to record the patient's vital signs every 4 hours?
A graphic sheet
A client has an external fixation device on his leg due to a compound fracture. The client says that the device and swelling makes his leg look ugly. Which nursing diagnosis should the nurse document in his care plan based on the client's concern?
Disturbed body image
A nurse is assessing a client admitted to the health care facility with angina. Which of the following would be most appropriate for the nurse to use to collect subjective data?
Interview
Which of the following is classified as a nursing diagnosis?
Grieving
Which of the following is an important element of implementation?
Documentation
The nurse has identified the following outcome for the client: The client will have a soft formed stool. Which error has the nurse made in writing the outcome?
The nurse has omitted the time frame.
SBAR
Situation
I am calling about <patient name and location>"
I have just assessed the patient.
Vital signs are..
I am concerned about the BP, temp, respiration, etc.
SBAR
Background
The patient's mental status is...
The skin is...
The patient is not or is on oxygen..
SBAR
Assessment
This is what I think the problem is..
The problem seems to be..
I am not sure what the problem is but the patient seems to be deteriorating..
The patient seems to be unstable and may get worse, we need to do something.
SBAR
Recommendation
I suggest or request that you..<what you want done>
Are there any tests needed:
If a change in treatment ordered then ask.