Analyzing Data to Make Informed Clinical Judgments

A nursing student is learning how to use critical thinking in formulating a plan of care. The student understands which of the following to be things needed to demonstrate that the process of thinking critically has begun? Select all that apply.

reserves a final opinion until further collecting data, explores other alternatives before making a decision, uses past knowledge and experience to analyze data

The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a client who has reported pain of a 7 (0 to 10 scale). What type of nursing diagnosis would this be considered?

Actual Nursing Diagnosis

The nursing student demonstrates a need for further teaching when they state which of the following?

Clients do not need to understand their problems.

A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse?

Make a referral to the dietician.

What can the nurse use to learn new information and add to their knowledge base?

Clinical experience.

A client who is being discharged after knee replacement surgery tells the nurse, "I know I need to work on my exercises, but I'm worried about falling because my balance isn't good." Which clinical judgment would be most appropriate for the nurse to document?

risk for impaired mobility

The nurse has completed a plan of care for a client having a total knee replacement. In order to develop goals which are realistic for the client, what should the nurse do prior to implementing the plan?

Ask the client for opinions and willingness to proceed with the interventions.

A nurse is teaching a client newly diagnosed with diabetes about diet and the exchange list. After several teaching sessions, the client continues to be confused and not sure about what to eat. The nurse's next best action is which of the following?

Schedule a dietary consult.

The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?

Diagnostic reasoning skills are required to interpret data accurately.

The nurse reviews a client's laboratory results, vital signs, and reported symptoms and then draws upon knowledge and previous experiences with similar clients to determine the most likely cause of the current condition. Which cognitive process is the nurse primarily using?

clinical reasoning

A nursing student demonstrates understanding of the different types of nursing problems when choosing the following to indicate that the client has the opportunity for an enhanced health state:

wellness diagnosis

The nurse is reviewing a client’s assessment findings: fatigue, shortness of breath with exertion, and bilateral ankle swelling. The nurse begins to organize these findings to determine the underlying problem. Which statement describes what action the nurse is taking?

The nurse is identifying patterns to determine the appropriate nursing diagnosis.

The nurse collects data from a client with a nonproductive cough and labored respirations at a rate of 24/minute. What other data should the nurse collect before formulating an appropriate nursing diagnosis?

status of breath sounds

A nurse interacts with four different clients one afternoon at the health clinic. The nurse is able to directly assist three of them and makes a referral for the fourth. Which of the following clients should the nurse refer to another professional?

An older adult client who needs daily therapy sessions to help them walk again after a hip fracture

The nurse receives a report on a group of clients. What client statement requires further clarification to ensure client safety? Select all that apply.

“I do not usually take insulin.” , “This looks like a new pill.” , “I fell at home last month.”