Chapter 5 - nursing process and critical thinking

1. What best defines the nursing process?

a. A method to ensure that the health care provider's orders are implemented

correctly.

b. A series of assessments that isolate a patient's health problem.

c. A framework for the organization of individualized nursing care.

d. A preset formula for the design of nursing care.

c. A framework for the organization of individualized nursing care.

The nursing process is a framework by which to organize individualized nursing care. Problem solving approach that enable the nurse to identify patient problems and potential problems.

6 dynamic and interrelated phase

1. Assessment

2. Diagnosis

3. Outcomes identificaiton

4. Planning

5. Implementation

6. Evaluation

The nurse is able to plan, deliver and evaluate nursing care is an orderly, scientific manner

2. All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment?

a. 53-year-old admitted with a perforated ulcer

b. 5-year-old admitted for the implant of grommets in the middle ear

c. 76-year-old admitted for a knee replacement

d. 40-year-old admitted for possible bowel obstruction

a. 53-year-old admitted with a perforated ulcer

A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illnesses.

-focus assessment is when the patient:

1.critically ill

2.disoriented

3.unable to respond.

Gather information about a SPECIFIC health problem.

Desired outcomes and performing nurse-patient contact through out (objective date) are also focus assessment.

Assessment = systematic, dynamic way to collect and analyze date about the client.

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3. What subjective data does the nurse record following a head-to-toe examination?

a. Rash on back

b. Prolonged nausea

c. Blood pressure of 190/100

d. White blood cell count of 19,000

b. Prolonged nausea

Another term for subjective data is symptoms, which cannot be observed or measured. This data must come from the patient

can be hidden until shared by the patient.

Ex. nausea, pain, fatigue, and anxiety

other terms: symptoms, subjective system, subjective cue

4. What objective data should the nurse include after a patient assessment?

a. Headache of 3 days' duration

b. Severe stomach cramps

c. Flatulence

d. Anxiety

c. Flatulence

Objective data are observable and measurable by people other than the patient

5. What is classified as information provided by the family when a patient is unable to provide data during assessment?

a. Primary

b. Secondary

c. Unreliable

d. Biased

b. Secondary

Date is obtained by Primary and Secondary sources

Primary source is the PATIENT

Secondary sources include:

1. family members

2. significant others

3. medical records

4. diagnostic procedures

5. previous nursing progress notes

6. health care team professionals (nurses, dietitians, physical therapist, respiratory etc.)

7. textbooks for resource.

pt unable due to deterioration of mental status, age, seriousness illness

6. What are the two primary methods used to collect data?

a. Written report by patient and family

b. Review of the chart and the nurse's notes

c. Interview and physical examination

d. Review of the health care provider's orders and the Kardex

c. Interview and physical examination

The two primary methods of collecting data are interviewing and physical examination.

1. Interview: biographic data: health history

2. physical examination: guided by subjective data: thorough assessment of body part or system, head to toe

Completed nurse health history and physical examination= allows nurse to establish a database for the patient. leads to ID of nursing diagnosis

7. The nurse writes two patient problems: (1) inadequate nutritional intake related to vomiting as manifested by a 3-lb weight loss and (2) risk for impaired skin integrity related to inadequate nutrition. What is the major difference between these diagnoses?

a. The second diagnosis needs no defined nursing interventions.

b. The second diagnosis needs medical intervention.

c. The second diagnosis will not need to be evaluated.

d. The second diagnosis reflects a problem that does not yet exist

d. The second diagnosis reflects a problem that does not yet exist

The actual patient problem represents a condition that is currently present. "Risk for" diagnoses are those that the patient is susceptible to, but not yet troubled by.

*Nursing diagnosis/pt problem statement: NANDA-I

*North American Nursing Diagnosis Association International

*Assessment and development of nursing diagnosis or patient

problem statement are the responsibility of the RN

the RN collaborates with the LPN when determining nursing diagnosis.

8. What framework does the establishment of priorities of care during the planning phase of the nursing process often use?

a. Erikson's developmental tasks

b. Piaget's cognitive table

c. Maslow's hierarchy of needs

d. Freud's classifications

c. Maslow's hierarchy of needs

A useful framework to guide prioritization is Maslow's hierarchy of needs.

1. physiological: food, eater, rest, warmth, shelter, clothing, sleep, breathing

2. safety and security

3. love and belonging

4. self esteem

5. self-actualization

9. What is an appropriate outcome statement for a patient with a patient problem of ineffective airway clearance related to thick secretions?

a. The patient will increase intake to 1000 mL daily to liquefy secretions.

b. The patient will cough more frequently within 3 days.

c. The patient will breathe better within 3 days.

d. The patient will perform deep-breathing exercises four times daily.

a. The patient will increase intake to 1000 mL daily to liquefy secretions.

The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague.

Adjectives: inability, insufficient, impaired, willingness.

10. What is the primary purpose of nursing interventions?

a. To support health care provider's orders

b. To provide direction for all caregivers

c. To provide broad, general statements

d. To clarify nursing principles

b. To provide direction for all caregivers

Nursing orders are necessary to provide instructions for all caregivers.

Nursing interventions activities that promote the achievement of the desired patient goal.

Interventions Include activities that nurse selects in partnership with the patient, to resolve a patient problem, monitor for the development of a potential problem or carry out physicians orders.

Physician prescribed or nurse prescribed

11. What documentation reflects implementation?

a. "Patient selected low-sugar snacks independently."

b. "Patient was medicated with Tylenol 500 mg PO for pain."

c. "Patient was ambulated for 15 minutes after lunch."

d. "Patient participated in group therapy session without reminder."

c. "Patient was ambulated for 15 minutes after lunch."

Implementation is the nurse carrying out nursing orders to promote outcome achievement. 5th phase of the nursing of the nursing process.

nurse should ensure the plan is implemented in a timely and safe manner.

Nursing interventions include

-nurse prescribed

-physician prescribed

activities

teaching, monitoring, providing, counseling, delegating, and coordinating.

12. Which nursing intervention is complete and correct?

a. "May 10: Unlicensed assistive personnel will ambulate patient. A. Nurse"

b. "Day nurse will cleanse wound and change dressings every day. May 10, A.Nurse"

c. "Unlicensed assistive personnel will serve 8 oz glass of juice at each meal, 5/10."

d. "P.M. nurse will ensure that heel protectors are in place before bedtime

b. "Day nurse will cleanse wound and change dressings every day. May 10, A.Nurse"

Nursing orders must be:

-signed

-dated

-have specific designation as to who will perform intervention

-specifics about time or frequency of the intervention.

13. A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occurred?

a. Omission

b. Variance

c. Failure

d. Error

b. Variance

A variance occurs when a projected outcome is not met.

possible reasons an outcome was not achieved include:

-patient's condition changed

-interventions where not performed

-interventions where not effective

-new problem developed

Variance analysis then is used to promote continuous quality improvement.

clinical pathway: multidisciplinary plan that incorporates evidence-based practice guidelines for high-risk, high-volume, high-cost types of cases while providing for optimal patient outcomes and maximized clinical efficiency.

14. During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent?

a. Symptoms

b. Data clustering

c. Signs of fluid overload

d. Urinary retention

b. Data clustering

The nurse organizes data, and those that are related are referred to as clustering.

obtained from health history, physical examination, psychosocial history, and related diagnostic procedures.

15. What type of assessment is performed continuously throughout nurse-patient contact?

a. Complete

b. Body systems

c. Focused

d. Subjective

c. Focused

Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan.

gather information of a specific health problem

Complete assessment: review and physical examination of all body systems. Cognitive, psychosocial, emotional, cultural, and spiritual

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16. What assists the nurse in the identification of patient problems?

a. Objective data

b. Subjective data

c. Data clustering

d. Validated data

c. Data clustering

Data clustering assists the nurse in determining patient problems.

-health history, physical examination, psychosocial history, related diagnostic problems

-defining characteristics.

-potential patient problems

-health promotion patient problem statements .

17. What organized approach might the nurse use when performing a complete physical examination?

a. Maslow's hierarchy of needs

b. A head-to-toe assessment

c. Subjective data collection

d. Objective data collection

b. A head-to-toe assessment

A head-to-toe format provides a systematic approach.

18. Who is the person responsible for analyzing and interpreting data to arrive at a patient problem?

a. Health care provider

b. LPN/LVN

c. RN

d. Technician

c. RN

The RN is responsible for analyzing and interpreting data.

19. What is the basis for designing and selecting nursing interventions to meet patient needs?

a. Patient problem

b. Care plan

c. Health care provider's orders

d. Nurse's notes

a. Patient problem

The patient problem is the basis for developing nursing interventions.

20. The patient is confined to bed rest, which contributes to immobility. What is bed rest considered in this situation?

a. Contributing to the patient's recovery

b. A risk factor

c. Difficult to maintain

d. A nursing responsibility

b. A risk factor

Risk factors are those that increase the susceptibility of a patient to a problem.

21. What is a patient problem considered when a problem is suspected but data to support it are lacking?

a. A syndrome patient problem

b. An actual patient problem

c. A "risk for" diagnosis

d. A possible patient problem

d. A possible patient problem

A possible patient problem requires additional data to confirm a problem or to complete a data cluster so that it can be related to a NANDA-I label.

22. When a nurse selects interventions to assist the patient to meet the needs demonstrated, the nurse is in which phase of the nursing process?

a. Assessment

b. Planning

c. Implementation

d. Evaluation

b. Planning

During the planning phase, the nurse connects nursing interventions to nursing orders.

Nursing Process

Assessment: gather of info

Diagnosis: pt problem

Planning: set goals and identify nursing actions

Implementation: perform nursing actions

Evaluation: Determine if goals met and outcomes achieved.

23. What is an important consideration when developing the care plan?

a. Ensure the number of interventions is limited.

b. Ensure the patient is involved in the process.

c. Ensure interventions will be easy to implement.

d. Ensure evaluation of the patient problems is possible.

b. Ensure the patient is involved in the process.

Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nor do they have to be easy. The patient problems are not evaluated; the patient's progress toward the outcome is.

24. From where are the "risk for" patient problems identified?

a. The care plan

b. The interventions

c. The assessment

d. The evaluation

c. The assessment

Patient problems should be identified from the assessment

25. What expected outcome exemplifies accepted criteria?

a. Nurse will assess vital signs every day

b. Resident will observe safety guidelines while smoking

c. Resident will take part in one activity daily for the next 90 days

d. Nurse will monitor O2 saturation to maintain at greater than 90%

c. Resident will take part in one activity daily for the next 90 days

Expected outcomes must be patient-centered, measurable, and refer to a time frame.

26. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

a. The patient complains of nausea.

b. The patient is vomiting.

c. The patient experiences tachycardia.

d. The patent is pacing the halls.

a. The patient complains of nausea.

Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of nausea is an example of subjective data. All other options are examples of objective data.

27. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

a. The patient is asleep.

b. The patient is tearful.

c. The patient has facial grimacing.

d. The patient states, "I hurt all over."

d. The patient states, "I hurt all over."

Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Stating "I hurt all over" is an example of subjective data. All other options are examples of objective data.

28. During an admission assessment, the nurse collects objective and subjective data. What is an example of subjective data?

a. The patient is coughing.

b. The patient has cyanosis of the lips.

c. The patient experiences tachypnea.

d. The patient complains of generalized discomfor

d. The patient complains of generalized discomfort

29. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

a. The patient complains of chest pain.

b. The patient states, "I feel nauseous."

c. The patient complains of feeling faint.

d. The patient is short of breath on exertion.

d. The patient is short of breath on exertion.

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Shortness of breath on exertion is an example of objective data. All other options are examples of subjective data.

30. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

a. The patient is jaundiced.

b. The patient states, "I am nervous."

c. The patient complains of palpitations.

d. The patient denies dizziness when ambulating.

a. The patient is jaundiced.

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient

31. During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data?

a. The patient complains of feeling depressed.

b. The patient states, "I hear voices in my head."

c. The patient complains of auditory hallucinations.

d. The patient is pacing back and forth while chanting.

d. The patient is pacing back and forth while chanting.

Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. Pacing back and forth while chanting is an example of objective data. All other options are examples of subjective data.

32. What is an example of an appropriate Patient problem?

a. Impaired skin integrity

b. Skin breakdown noted

c. Turn patient every 2 hours

d. The patient has scabies on his back

a. Impaired skin integrity

"Impaired skin integrity" is an example of a patient problem. "Skin breakdown noted" is an example of a charting entry, "turn patient every 2 hours" is a nursing intervention, and "scabies" is a medical diagnosis.

33. What is an example of an appropriate patient problem?

a. Constipation

b. Patient complains of constipation

c. Need for laxatives

d. Patient has a duodenal ulcer

a. Constipation

Constipation is an example of a patient problem, a patient complaining of constipation is an example of a charting entry, a need for laxatives is an example of a patient need, and a patient has a duodenal ulcer is an example of a medical diagnosis.

34. A nurse is formulating a patient problem. What is an example of an appropriately written patient problem?

a. Risk for impaired skin integrity related to physical immobilization

b. Physical immobilization secondary to risk for impaired skin integrity

c. Risk for impaired skin integrity related to diagnosis of decubitus ulcers

d. Physical immobilization secondary to decreased cognitive ability

a. Risk for impaired skin integrity related to physical immobilization

Risk for impaired skin integrity related to physical immobilization is the only appropriately written patient problem. All other options are not listed as NANDA-I approved patient problems.

35. Which is an example of a patient problem?

a. Pneumonia

b. Diabetes mellitus

c. Impaired skin integrity

d. Congestive heart failure

c. Impaired skin integrity

Impaired skin integrity is the only example of a patient problem; all other options are examples of medical diagnoses.

36. Which is an example of a medical diagnosis?

a. Constipation

b. Diabetes mellitus

c. Impaired skin integrity

d. Altered nutrition: less than body requirements

b. Diabetes mellitus

Diabetes mellitus is the only example of a medical diagnosis; all other options are examples of patient problems.

37. Which is an example of a medical diagnosis?

a. Pain

b. Anxiety

c. Pneumonia

d. Impaired skin integrity

c. Pneumonia

Pneumonia is the only example of a medical diagnosis; all other options are examples of patient problems.

1. Which are acceptable secondary sources for data? (Select all that apply.)

a. Patient

b. Family members

c. Other health professionals

d. Diagnostic reports

e. Textbooks

b. Family members

c. Other health professionals

d. Diagnostic reports

e. Textbooks

A patient is not a secondary source. The patient is the primary data source.

2. Which are official categories of patient problems? (Select all that apply.)

a. Actual

b. Risk

c. Wellness

d. Syndrome

e. Potential

a. Actual

b. Risk

c. Wellness

d. Syndrome

Actual, risk, wellness, and syndrome are the four categories of patient problems.

3. Which are considered phases of the nursing process? (Select all that apply.)

a. Diagnosis

b. Prediction

c. Assessment

d. Evaluation

e. Implementation

f. Outcome identification

a. Diagnosis

c. Assessment

d. Evaluation

e. Implementation

f. Outcome identification

The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment, outcome identification, planning, implementation, and evaluation. Prediction is not a phase of the nursing process.

1. NANDA International meets to reorganize diagnosis labels and language every 2 ____________.

Years

NANDA International meets every two years to revise language, form, and diagnosis labels.

2. The standards that name and measure patient ________ are referred to as NOC (Nursing Outcome Classification).

Outcomes

NOC sets up outcome criteria based on a patient problem.

3. The document that outlines a _________________ plan for care interventions over a specified time frame is called a clinical pathway, critical path, action plan, or care map.

Multidisciplinary

A clinical pathway is an organized multidisciplinary plan over a specified time frame, which outlines aspects of patient care. They are also called critical paths, action plans, and care maps.

4. A systematic method by which nurses plan and provide care for patients is known as the nursing ____________.

process

The nursing process serves as the organizational framework for the practice of nursing. It is a systematic method by which nurses plan and provide care for patients.

5. A systemic, dynamic way to collect and analyze data about a patient that includes physiologic data as well as psychological, sociocultural, spiritual, economic, and lifestyle factors is known as ______________________.

assessment

The American Nurses Association (ANA) defines assessment as "a systematic, dynamic way to collect and analyze data about a patient, the first step in delivering nursing care. Assessment includes not only physiologic data, but also psychological, sociocultural, spiritual, economic, and lifestyle factors as well."

6. Any health care condition that requires diagnostic, therapeutic, or educational actions is known as a ______________.

problem

A problem is any health care condition that requires diagnostic, therapeutic, or educational actions

7. A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community is known as a nursing ___________.

Diagnosis

A patient problem is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.

8. The human responses to health conditions/life processes that exist in an individual, family, or community are known as a(n) _________ patient problem.

Actual

An actual patient problem is described as the human responses to health conditions/life processes that exist in an individual, family, or community.

9. Human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community are known as a(n) __________ patient problem.

Risk

A risk patient problem is defined as the human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.

10. Human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement are known as a _____________ patient problem

wellness

A wellness patient problem is defined as human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement.

11. The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures is known as a _________ diagnosis.

medical

A medical diagnosis is the identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures.

12. A health care system that provides control over health care services for a specific group of individuals in an attempt to control cost is known as ___________ care.

managed

Managed care is a health care system that provides control over health care services for a specific group of individuals in attempts to control cost.

13. A multidisciplinary plan that schedules clinical ____________ over an anticipated time frame for high-risk, high-volume, and high-cost types of cases is known as a critical pathway.

interventions

A critical pathway is a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, and high-cost types of cases.

Definition of these nursing diagnoses:

Actual: problem that has occurred

Risk: potential problem

Syndrome: cluster of nursing diagnosis

Health promotion: readiness to enhance health