CH 4 The Nursing Process and Critical Thinking
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The nurse who uses the nursing process will:
help reduce the obvious signs of discomfort.
help the patient adhere to the primary care provider's treatment protocol.
approach the patient's disorder in a step-by-step method.
make all significant nursing care decisions involving patient care.
ANS: C
The nursing process is a collaborative process used throughout the patient's stay. It is an organized method for identifying and meeting patient needs in a step-by-step manner.
DIF: Cognitive Level: Knowledge
TOP: Nursing Process
MSC: NCLEX: N/A
REF: p. 48
OBJ: Theory #1
KEY: Nursing Process Step: N/A
A nurse will arrive at a nursing diagnosis through the nursing process step of:
planning.
evaluation.
research.
assessment.
ANS: D
As a result of the nursing assessment, a nursing diagnosis is established.
DIF: Cognitive Level: Comprehension
REF: p. 50|Table 4-2
OBJ: Theory #2
TOP: Nursing Diagnosis
MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A
In the collaborative process of delivering care based on the nursing process, the responsibility of the LPN/LVN is to:
collect data of health status.
select a nursing diagnosis.
organize data to help the RN evaluate patient progress.
prioritize nursing diagnoses for more effective care.
ANS: A
The LPN/LVN collects data of the patient's health status to assist the RN in selecting a nursing diagnosis.
DIF: Cognitive Level: Comprehension REF: p. 49|Table 4-1
OBJ: Theory #2
TOP: Critical Thinking
MSC: NCLEX: N/A
KEY: Nursing Process Step: N/A
The participants of the planning stage of the nursing process during which the health goals are defined include:
the RN
the health team led by the RN.
the health team, the patient, and the patient's family.
the health team as directed by the physician.
ANS: C
The planning stage during which the health goals are defined are best shared by the entire health team, the patient, and the patient's family for the optimum outcome.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process
MSC: NCLEX: N/A
REF: p. 48
OBJ: Theory #1
KEY: Nursing Process Step: N/A
When a resident in the nursing home complains of constipation, the nurse performs a digital rectal examination and finds a hard fecal mass. This is an example of:
implementation.
nursing diagnosis.
assessment.
evaluation.
ANS: C
The examination to confirm and affirm the complaint of constipation is an assessment.
DIF: Cognitive Level: Application
REF: p. 48|Table 4-1
OBJ: Theory #1
TOP: Nursing Process
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
The nurse completing morning assessments on a patient who is sitting up in bed is told by the patient, "I'm having trouble breathing—I can't seem to get enough air." The best nursing response is to:
notify the doctor as soon as he or she comes in later in the morning.
finish the vital signs for the assigned patients, and then notify the charge nurse.
reassure the patient, if his blood pressure and pulse are normal.
notify the charge nurse immediately of the patient's statement.
ANS: B
The nurse should finish the assessment in order to confirm the complaint and inform the charge nurse.
DIF: Cognitive Level: Analysis
OBJ: Theory #1
REF: p. 50|Table 4-2
TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
The order in which the nursing process is approached is:
planning, assessment, implementation, nursing diagnosis, evaluation.
nursing diagnosis, evaluation, assessment, implementation, planning.
assessment, nursing diagnosis, planning, implementation, evaluation.
evaluation, nursing diagnosis, planning, implementation, assessment.B
ANS: C
The order of assessment nursing diagnosis, planning, implementation, and evaluation sets up a basis for an organized approach to nursing care.
DIF: Cognitive Level: Knowledge
OBJ: Theory #1
TOP: Nursing Process
REF: p. 49 Box 4-1
KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
Once the nursing plan has been initiated, the nursing care plan will:
stay in place until all nursing goals have been met.
change as the patient's condition changes.
remain on the patient record to show progress.
be given to the patient for final approval.
ANS: B
The nursing care plan is always a work in progress and will change as the patient condition changes.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process
MSC: NCLEX: N/A
REF: p. 50
OBJ: Theory #2
KEY: Nursing Process Step: N/A
When a patient states, "I can't walk very well," the first problem-solving step would be to:
consider alternatives such as a wheelchair or walker.
find out what the problem is, such as weakness or poor balance.
choose the alternative with the best chance of success.
consider the outcomes of the choices, such as danger of falling with a walker.
ANS: B
Defining the problem clearly assists in the interventions to reduce the problem.
DIF: Cognitive Level: Analysis
REF: p. 50
OBJ: Theory #5
TOP: Problem Solving
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
A student nurse can begin to develop critical thinking skills by means of:
working with a more experienced nurse.
questioning every statement made by instructors to be sure of its correctness.
memorizing class notes for tests and studying all night for big tests.
listening attentively and focusing on the speaker's words and meaning.
ANS: D
Critical thinking involves foundation skills such as effective reading and writing and attentive listening.
DIF: Cognitive Level: Comprehension
TOP: Critical Thinking
MSC: NCLEX: N/A
REF: p. 50
OBJ: Theory #7
KEY: Nursing Process Step: N/A
When a nurse prioritizes the patient care, consideration is given to:
completing assessments before mid-shift.
considering situations that may result in an alteration of health.
assuming all health care activities for a group of patients.
identifying who can assist with the aspect of care.
ANS: B
Priority setting includes addressing health endangering situations and physiological needs first.