Term
During the change of shift report the night nurse reports " Mr Sierra told me that he has had a bad experience w/ surgery in the past. I didnt get a chance to talk to him about it. We had a # of clients requiring procedures last nght. He seems a bit anxious this morning". As the day shift nurse, going to visit Mr. Sierra to clarify what experience he has had w/ surgery is an example of which critical thinking attitude?
1. Integrity
2. Discipline
3. Confidence
4. Perseverance |
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Definition
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Term
When you enter Mr. Ryan's room, he tells you " I am not happy with the way the client care tech did my bath. He just seemed to be in a hurry and did not wash my back like I asked." You decide to go talk to the tech to learn his side of the story as well. This is an example of:
1. Fairness
2. Curiousity
3. Risk Taking
4. Responsibility |
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Definition
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Term
The surgical unit has intiated the use of a pain rating scale, which is to be used to assess clients pain severity during their postooperative recovery. Susan, the RN assigned to Ms. Wills, looks at her pain flow sheet to see Ms. Wills pain scores over the last 24 hours. Use of the pain scale is an example of which intellectual standard?
1. Deep
2. Relevant
3. Consistent
4. Significant |
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Definition
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Term
During the day the nurse spends time instructing a client in how to self administer insulin. After discussing the techniques and demonstrating an injection, the nurse has the client try it. After two attempts, the client obviously does not understand how to prepare the correct dose. When the nurse returns to the medication room, he discusses the situation with the charge RN, reviewing his approach with the client & asking for her suggestions on his technique. This is an example of
1. Reflection
2. Risk Taking
3. Problem Solving
4. Client assessment |
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Definition
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Term
A nurse uses an institution procedure manual to to confirm how to interpret a foley catheter. The level of critical thinking the RN is using is:
1. Commitment
2. Scientific Method
3. Basic critical thinking
4. Complex critical thinking |
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Definition
| #3, basic critical thinking |
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Term
a client had hip surgery 24 hours ago The RN refers to the written plan of care, noting that the client has a drainage device collecting wound drainage. The MD is to be notified when drainage in the device exceeds 100ml for the day. When the nurse enters the room, the nurse loks at the device and carefullt notes the amount of drainage currently in the device. This is an example of:
1. Planning
2. Evaluation
3. Intervention
4. Assessment |
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Definition
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Term
The nurse asks a client how she feels about her impending surgery for breast cancer. Before the discussion, the nurse reviewed the description in his textbook of loss and grief in addition to therapeutic communication principles. The critical thinking component involved in the nurses review of the literature is:
1. Experience
2. Problem solving
3. Knowledge application
4. Clinical decision making |
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Definition
| #3, knowledge application |
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Term
The purpose of assessment is to:
1. make a diagnostic conclusion
2. Delegate nursing responsibility
3. Teach the client about his or her health
4. Establish a database concerning the client |
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Definition
| #4, establish a database concerning the client |
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Term
Assessment data must be descriptive, concise, and complete. An assessment should not include:
1. Subjective data from the client
2. A detailed physical exam
3. The use of interpersonal and cognitive skills
4. Inferences or interpretative statements not supported with data |
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Definition
| #4, inferences or interpretative statements not supported with data |
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Term
A nurse assesses a client who comes to the pulmonary clinic " Tell me what medications you are on for your breathing problem. I see from your list your last visit that Dr. Russell recommended routine exersize. Can you tell me how how successful you have been in following his plan? " The nurse's assessment covers which of Gordon's functional health patterns?
1. Value belief pattern
2. Cognitive perceptual pattern
3. Coping stress tolerance pattern
4. Health perception-health management pattern |
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Definition
| #4, Health perception-management pattern |
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Term
The nurse asks a client "Ms. Neil, describe for me your typical diet over a 24 hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a client interview?
1. Working
2. Orientation
3. Termination |
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Definition
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Term
During data clustering a nurse:
1. Provides documentation of nursing care
2.Reviews data with other health care providers
3. Makes inferences about patterns of information
4. Organizes cues into patterns that lead to identifying nursing diagnoses |
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Definition
| #4,Organizes cues into patterns that lead to identifying nursing diagnoses |
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Term
What type of interview techniques does the nurse use when asking the question, “Do you have pain or cramping?” (Choose all that apply.)
1. Active listening
2. Open-ended questioning
3. Closed-ended questioning
4. Problem-oriented questioning |
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Definition
| #3,Closed-ended questioning |
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Term
7. What techniques encourage a client to tell his or her full story? (Choose all that apply.)
1. Active listening
2. Back channeling
3. Use of open-ended questions
4. Use of closed-ended questions |
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Definition
| #s1,2,3-Active listening,Back channeling, Use of open-ended questions |
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Term
You gather the following assessment data, which of the following cues form a pattern? (Choose all that apply.)
1. Client is restless.
2. Fluid intake for 8 hours is 800 mL.
3. Client states feels short of breath.
4. Client has drainage from surgical wound.
5. Respirations are 24 per minute and irregular.
6. Client reports loss of appetite for over 2 weeks. |
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Definition
| #s 1,3,5:1. Client is restless, client states feels short of breath & Respirations are 24 per minute and irregular. |
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Term
A nursing diagnosis is:
1. The diagnosis and treatment of human responses to health and illness
2. The advancement of the development, testing, and refinement of a common nursing language
3. A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes
4. The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests |
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Definition
| #3, A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes |
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Term
Lisa reviews data she has regarding Ms. Devine's pain symptoms. She compares the defining characteristics for acute pain with those for chronic pain. In the end she selects acute pain as the correct diagnosis. This is an example of Lisa avoiding an error in:
1. Data collection
2. Data clustering
3. Data interpretation
4. Making a diagnostic statement |
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Definition
| #4, Making a diagnostic statement |
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Term
One of the purposes of the use of standard formal nursing diagnostic statements is to:
1. Evaluate nursing care
2. Gather information on client data
3. Help nurses to focus on the role of nursing in client care
4. Facilitate understanding of client problems among health care providers |
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Definition
| 4. Facilitate understanding of client problems among health care providers |
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Term
The nursing diagnosis readiness for enhanced communication is an example of a(n):
1. Risk nursing diagnosis
2. Actual nursing diagnosis
3. Potential nursing diagnosis
The nursing diagnosis readiness for enhanced communication is an example of a(n):
1. Risk nursing diagnosis
2. Actual nursing diagnosis
3. Potential nursing diagnosis
4. Wellness nursing diagnosis |
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Definition
| #4, Wellness nursing diagnosis |
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Term
The nursing diagnosis hypothermia is an example of a(n):
1. Risk nursing diagnosis
2. Actual nursing diagnosis
3. Potential nursing diagnosis
4. Wellness nursing diagnosis |
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Definition
| 2. Actual nursing diagnosis |
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Term
The word impaired in the diagnosis Impaired physical mobility is an example of a:
1. Descriptor
2. Risk factor
3. Related factor
4. Nursing diagnosis |
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Definition
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Term
In the examples listed below, which nurse is acting to avoid a data collection error?
1. The nurse asks a colleague to chart his or her assessment data.
2. The nurse considers conflicting cues in deciding the correct nursing diagnosis.
3. The nurse assessing the edema in a client's lower leg is unsure of its severity and asks a co-worker to check it with him or her.
4. After doing an assessment the nurse critically reviews his or her level of comfort and competence with interview and physical assessment skills. |
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Definition
| #3 The nurse assessing the edema in a client's lower leg is unsure of its severity and asks a co-worker to check it with him or her. |
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Term
“Unhappy and worried about health” is not a scientifically based nursing diagnosis, and it can lead to error in:
1. Data collection
2. Data clustering
3. Medical diagnosis
4. “Unhappy and worried about health” is not a scientifically based nursing diagnosis, and it can lead to error in:
1. Data collection
2. Data clustering
3. Medical diagnosis
4. Diagnostic statement |
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Definition
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Term
Casey is reviewing a client's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as:
1. Identifying the clinical sign instead of an etiology
2. Identifying a diagnosis based on prejudicial judgment
3. Identifying the diagnostic study rather than a problem caused by the diagnostic study
4. Identifying the medical diagnosis instead of the client's response to the diagnosis |
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Definition
| 4. Identifying the medical diagnosis instead of the client's response to the diagnosis |
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Term
Which of the following are defining characteristics for the nursing diagnosis impaired urinary elimination? (Choose all that apply.)
1. Nocturia
2. Frequency
3. Urine retention
4. Inadequate urinary output
5. Receiving intravenous fluids
6. Sensation of bladder fullness |
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Definition
1. Nocturia
2. Frequency
3. Urine retention |
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Term
Sheila is assigned to a client who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment Sheila anticipates the need to monitor the client's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The client is in pain and will not be able to eat or drink until intestinal function returns. Sheila will have to establish priorities of care in which of the following situations? (Choose all that apply.)
1. The family comes to visit the client.
2. The client expresses concern about pain control.
3. The client's vital signs change, showing a drop in blood pressure.
4. The charge nurse approaches Sheila and requests a report at end of shift. |
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Definition
2. The client expresses concern about pain control.
3. The client's vital signs change, showing a drop in blood pressure. |
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Term
Sheila's client signals with her call light. Sheila enters the room and finds the drainage tube disconnected, the IV has 100 ml of fluid remaining, and the client has asked to be turned. Which of the following should Sheila perform first?
1. Reconnect the drainage tubing.
2. Inspect the condition of the IV dressing.
3. Improve client's comfort, and turn to her side.
4. Go to the medication room, and obtain the next IV fluid bag. |
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Definition
| 1. Reconnect the drainage tubing. |
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Term
When does implementation begin as the fourth step of the nursing process?
1. During the assessment phase
2. Immediately, in some critical situations
3. After the care plan has been developed
4. After there is mutual goal setting between nurse and client |
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Definition
| 3. After the care plan has been developed |
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Term
Mr. Switzer is a 34-year-old client who had a surgical repair of an abdominal hernia this morning. At 12 noon the nurse records Mr. Switzer's vital signs on the recovery room flow sheet. The recording of vital signs is an example of:
1. Psychomotor skill
2. Indirect care measure
3. Physical care technique
4. Anticipating complications |
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Definition
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Term
Before beginning insertion of a client's indwelling urinary catheter, the nurse considers the steps to take to avoid the possibility of breaking sterile technique, which could cause a urinary tract infection. This is an example of what type of decision making?
1. Identifying areas of assistance
2. Reviewing possible consequences of a nursing action
3. Reassessing the clinical situation to revise the care plan
4. Determining the probability of all consequences of the catheterization |
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Definition
| 2. Reviewing possible consequences of a nursing action |
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Term
Interdisciplinary care plans represent:
1. All nursing personnel having input in the care plan
2. Contributions of all disciplines caring for the client
3. The client's expressed wishes and advance directives
4. Physicians and nurses working together to develop a plan of care |
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Definition
| 2. Contributions of all disciplines caring for the client |
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Term
Environmental factors heavily affect a client's care. Your first concern for the client includes which of the following?
1. Safety
2. Nurse staffing
3. Confidentiality
4. Adequate pain relief |
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Definition
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Term
In which of the following examples is a nurse applying critical thinking attitudes when performing a dressing change?
1. Following the procedural guideline for a dressing change
2. Seeking necessary knowledge on the steps of the procedure
3. Showing confidence in knowing which dressing materials to use
4. Being sure that the dressing covers the entire wound completely. |
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Definition
| 3. Showing confidence in knowing which dressing materials to use |
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Term
Which steps do you follow when you are asked to perform a procedure with which you are unfamiliar? (Choose all that apply.)
1. Seek necessary knowledge.
2. Reassess the client's condition.
3. Collect all equipment necessary.
4. Have an experienced nurse available to assist.
5. Consider all possible consequences of the procedure. |
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Definition
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Term
A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. After suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides a glass of water for the client. Which of the following is an evaluative measure used by the nurse?
1. Suctioning the airway
2. Sitting client up in bed
3. Auscultating lung sounds
4. Asking client to describe type of discomfort |
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Definition
| 3. Auscultating lung sounds |
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Term
A nurse caring for a client with pneumonia sits the client up in bed and suctions the client's airway. After suctioning, the client describes some discomfort in his abdomen. The nurse auscultates the client's lung sounds and provides a glass of water for the client. Which of the following is an appropriate evaluative criterion used by the nurse? (Choose all that apply.)
1. Client drinks contents of water glass.
2. Client's lungs are clear to auscultation in bases.
3. Client reports abdominal pain on scale of 0 to 10.
4. Client's rate and depth of breathing are normal with head of bed elevated. |
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Definition
| 2. Client's lungs are clear to auscultation in bases & 4. Client's rate and depth of breathing are normal with head of bed elevated. |
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Term
The evaluation process, which determines the effectiveness of nursing care, includes five elements, one being interpreting findings. Which of the following is an example of interpretation?
1. Evaluating the client's response to selected nursing interventions
2. Selecting an observable or measurable state or behavior that will reflect goal achievement
3. Reviewing the client's nursing diagnoses and establishing goals and outcome statements
4. Matching the results of evaluative measures with expected outcomes to determine client's status |
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Definition
| 3. Reviewing the client's nursing diagnoses and establishing goals and outcome statements |
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Term
A goal specifies the expected behavior or response that indicates:
1. The specific nursing action was completed
2. The validation of the nurse's physical assessment
3. The nurse has made the correct nursing diagnoses
4. Resolution of a nursing diagnosis or maintenance of a healthy state |
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Definition
| 4. Resolution of a nursing diagnosis or maintenance of a healthy state |
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Term
A client is recovering from surgery for removal of an ovarian tumor. It is one day after her surgery. Because she has an abdominal incision and dressing, the nurse has selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal statement for the diagnosis?
1. Client will remain afebrile to discharge.
2. Client's wound will remain free of infection by discharge.
3. Client will receive ordered antibiotic on time over next 3 days.
4. Client's abdominal incision will remain covered with a sterile dressing for 2 days. |
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Definition
| 2. Client's wound will remain free of infection by discharge. |
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Term
Unmet and partially met goals require the nurse to do which of the following? (Choose all that apply.)
1. Redefine priorities
2. Continue intervention
3. Discontinue care plan
4. Gather assessment data on a different nursing diagnosis
5. Compare the client's response with that of another client |
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Definition
1. Redefine priorities
2. Continue intervention |
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