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Question 1

A nurse’s personal moral code is to assist all patients to
the best of one’s ability. What blended skill would the
nurse use when seeking out special services for a
homeless patient with a diabetic foot ulcer?

A. Cognitive
B. Technical
C. Interpersonal
D. Ethical/Legal

Answer 1

D: Ethical/Legal

Rationale: Using ethical/legal skills is the best answer
as it involves following a moral code and acting
professionally. Cognitive skills involve thinking through a
situation to achieve outcomes. Technical skills relate to
the proper use of equipment. Interpersonal skills are
used to develop caring relationships.

Question 2

Which step of the nursing process is a nurse using when
analyzing patient data to determine a patient’s strengths
following a CVA?

A. Assessing
B. Diagnosing
C. Planning
D. Implementing
E. Evaluating

Answer 2

B. Diagnosing
Rationale: The diagnosing step involves analyzing
patient data to determine strengths and weaknesses. The
assessing step refers to the collection, validation, and
communication of patient data. In the planning step, the
nurse determines patient outcomes and related nursing
interventions, and in the implementing step, the nurse
carries out the plan. When evaluating, the nurse
measures the extent to which the patient achieved
outcomes.

Question 3

Which of the following characteristics of the nursing
process describes the interaction and overlapping of
steps within the process itself?

A. Systematic
B. Dynamic
C. Interpersonal
D. Universally Applicable

Answer 3

B: Dynamic

Rationale: The nursing process is dynamic in that there
is much interaction and overlapping of the steps. It is
systematic since it is an ordered sequence of activities.
Interpersonal refers to the human being at the heart of
nursing. The nursing process is universally applicable in
that it is a framework for all nursing activities

Question 4

List five characteristics of the nursing process.

Answer 4

Systematic: part of an ordered sequence of activities

Dynamic: great interaction and overlapping among the
five steps

Interpersonal: human being is always at the heart of
nursing

Outcome oriented: nurses and patients work together to
identify outcomes

Universally applicable: a framework for all nursing
activities

Question 5

Steps in Concept Mapping:

Answer 5

1. Collect patient problems and concerns on a list.
2. Connect and analyze the relationships.
3. Create a diagram.
4. Keep in mind key concepts: the nursing process, holism,
   safety, and advocacy

Question 6

Reflection IN action:

Answer 6

Happens in the here and now of the activity and is
also known as “thinking on your feet.”

Question 7

Reflection ON action:

Answer 7

Occurs after the fact and involves thinking through a
situation that has occurred in the past.

Question 8

Reflection FOR action:

Answer 8

Helps the person to think about how future actions
might change as a result of the reflection.

Question 9

critical thinking indicators: behaviors that
demonstrate the knowledge, characteristics, and skills
that promote critical thinking in clinical practice, such as:

Answer 9

-Independent thinking
-Intellectual curiosity
-Intellectual humility
-Intellectual empathy
-Intellectual courage
-Intellectual perseverance
-Fair-mindedness

Question 10

List 6 Critical Thinking Skills Used in Nursing
Practice:

Answer 10

1. Interpretation involves clarifying meaning, such as determining
   the significance of laboratory values, vital signs, and physical
   assessment data. It also includes understanding the meaning of a
   patient’s behavior or statements.
2. Analysis is determining the patient’s problems based on
   assessment data. At times, the actual problem can’t be validated
   initially, but several possibilities, or arguments can be identified.
3. Evaluation is identifying expected patient outcomes and assessing
   whether or not they’re met. If not met, the nurse ascertains why.
4. Inference is about drawing conclusions. For example, the nurse
   determines when a patient’s health status improves or declines
   through careful monitoring.
5. Explanation is the ability to justify actions. The nurse implements
   interventions based on research or other sources of evidence.
6. Self-regulation is the process of examining one’s practice and
   correcting or improving it if necessary.

Question 11

Discuss the relationship of the nursing process to critical
thinking:

Assessment:

Answer 11

Consider the situation
Collect information
Process that information

Question 12

Discuss the relationship of the nursing process to critical
thinking:

Diagnosis:

Answer 12

Identify Issues

Question 13

Discuss the relationship of the nursing process to critical
thinking:

Planning:

Answer 13

Establish goals

Question 14

Discuss the relationship of the nursing process to critical
thinking:

Implementation:

Answer 14

Take action

Question 15

Discuss the relationship of the nursing process to critical
thinking:

Evaluation:

Answer 15

Evaluate the outcomes
Adjust goals and actions according to outcome

Question 16

A nurse is reading a journal article about providing individualized care. Which aspect would the nurse most likely read about as the almost universally accepted method for providing nursing care?

Nursing process

Clinical reasoning

Experience Reflection

Reflection

Answer 16

Nursing process

Question 17

The nursing process is based upon the process of problem solving. The nurse attempts to obtain a blood pressure on the client’s right arm, then on the left arm, then on the left leg, and finally on the right leg, where the blood pressure is obtained. What type of problem solving did the nurse use?

Trial-and-error problem solving

Critical thinking

Intuitive thinking

Scientific problem solving

Answer 17

Trial-and-error problem solving

Question 18

A nurse is evaluating a client’s care. During this phase of the nursing process, which behavior by the nurse indicates critical thinking?

Evidence interpretation

Outcome attainment

Data validation

Reflective skepticism

Answer 18

Outcome attainment

Question 19

The nurse is caring for a client with an identified nursing concern of fluid volume deficiency. The nurse has implemented the plan of care and on evaluation finds that the client continues to exhibit symptoms of fluid volume deficiency. What should the nurse do next?

Develop an additional nursing concern to meet the client’s health needs.

Change the nursing concern, because the client’s problem was falsely identified.

Reassess the client for more symptoms of fluid volume deficiency.

Modify the plan of care and interventions to meet the client’s needs.

Answer 19

Modify the plan of care and interventions to meet the client’s needs.

Question 20

Which statement regarding critical thinking in nursing is true?

It makes judgments based on conjecture.

It shows trends and patterns in client status.

It is a systematic way of thinking.

It supplies validation for reimbursement.

Answer 20

It is a systematic way of thinking.

Question 21

A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client’s room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment?

Document that the client is talking back to the voices in the client’s head.

Document this assessment based on the client’s behaviors.

Do not document this assessment because the client could be using a wireless device to talk to family.

Do not document this assessment because it is subjective.

Answer 21

Document this assessment based on the client’s behaviors.

Question 22

Which statement is true of the nursing process?

Trial-and-error problem solving is an efficient use of the nurse’s time.

Scientific problem solving can occur within the nursing process.

It is more appropriate in medical surgical settings than community health care.

It is a valid alternative to using intuition to respond to nursing situations.

Answer 22

Scientific problem solving can occur within the nursing process.

Question 23

Which is a characteristic of person-centered care?

It is independent of other disciplines.

It involves general care for all clients.

It can be used in hospital settings.

It is a framework for providing care.

Answer 23

It is a framework for providing care.

Question 24

A nurse has developed a plan of care for an adult client. What nursing function is important when using the identified nursing concerns to guide the care of this client?

Add a new nursing concern in the nurse’s own words to individualize the plan of care.

Prioritize the nursing concerns.

Keep resolved nursing concerns as part of the plan of care in case the related problems return.

Do not allow the client to review the nursing concerns identified for them.

Answer 24

Prioritize the nursing concerns.

Question 25

A client has had major abdominal surgery and just returned to the unit from the operating room. The nursing priority is to:

complete the postoperative assessment.

expect the client to be drowsy, and let the client rest.

administer pain medication.

evaluate the abdominal dressing for drainage.

Answer 25

complete the postoperative assessment.

Question 26

The nurse analyzes client data to identify client strengths and health problems that independent nursing interventions can prevent or resolve. Which step of the nursing process is the nurse performing?

Evaluating

Assessing

Diagnosing

Implementing

Question 27

The nurse is assisting with the creation of a plan of care for a client with newly diagnosed diabetes mellitus. When creating the plan of care, what is the priority action for the nurse?

implementing the standard plan of care for all clients with diabetes mellitus

involving the client with all the steps of the process in care development

requiring the client to evaluate the plan of care after implementation

ensuring the client is informed after decisions are made with care delivery

Answer 27

involving the client with all the steps of the process in care development

Question 28

The nurse is caring for a client who presents with polydipsia, polyphagia, and polyuria. The client’s laboratory test results reveal an increased HgbA1C level, which could indicate increased blood glucose levels. What is the next step for the nurse to take based on the nursing process?

Identify outcomes for the client with the client’s input.

Analyze the data and create an individualized nursing concern for care planning.

Administer a prescribed medication to decrease the client’s blood glucose level.

Follow up with the client later to determine whether the client’s laboratory test results improve.

Answer 28

Analyze the data and create an individualized nursing concern for care planning.

Question 29

What type of intervention is the nurse performing when the nurse observes the spouse of a postoperative client performing the client’s dressing change?

maintenance

technical

surveillance

supervisory

Answer 29

supervisory

Question 30

A nurse is working with a group of staff members to address the needs of a client as they develop the client’s interdisciplinary plan of care. Which question if asked by the nurse addresses the standard of breadth when judging the group’s thinking?

“Is there another way to look at this situation?”

“Could you be more specific in your observations?”

“How could we find out whether that is true?”

“Could you elaborate on that point a bit more?”

Answer 30

“Is there another way to look at this situation?”

Question 31

The nurse is caring for an obese client who needs to be turned every 2 hours. Which action by this nurse is an example of reflection-for-action?

After turning the client alone, the nurse realizes that the nurse should have insisted on having help.

During the first attempt to turn the client, the nurse realizes the need for assistance and calls the front desk for help.

The nurse decides to turn the client every 4 hours because everyone is too busy to help.

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client’s plan of care.

Answer 31

Reflecting on prior experience and best practice, the nurse includes assistance with turning in the client’s plan of care.

Question 32

Which activity is the clearest example of the evaluation step in the nursing process?

Giving the client an as-needed dose of captopril in light of an abnormal blood pressure reading

Recognizing that the client’s blood pressure of 172/101 is an abnormal finding

Checking the client’s blood pressure 30 minutes after administering captopril

Taking a client’s blood pressure on both arms at the beginning of a shift

Answer 32

Checking the client’s blood pressure 30 minutes after administering captopril

Question 33

Which term refers to a purposeful activity that leads to action, improvement of practice, and better client outcomes?

Evaluation

Memorization

Assessment

Reflection

Answer 33

Reflection

Question 34

The nurse is developing a plan of care for a client with a fractured femur who is in traction and will be restricted to bed for some time. Which domain should the nurse consider when developing a nursing diagnosis based on this client’s musculoskeletal health problems?

nutrition

self-perception

health promotion

activity and rest

Answer 34

activity and rest

Question 35

The nurse is performing an assessment on a client who reports having a rash on the back that is red and raised. What would be the next nursing action?

Document the rash in the client’s chart.

Establish a nursing concern of altered skin integrity.

Report the rash to the health care provider.

Assess the client’s back visually.

Answer 35

Assess the client’s back visually.

Question 36

A nurse administers intravenous fluids to a client diagnosed with dehydration. After the fluids are completed, the client’s blood pressure is increased and pulse is decreased. During the final phase of the nursing process, what should the nurse do?

Formulate a plan of care based on risk for dehydration.

Check the client’s skin turgor.

Administer an additional liter of intravenous fluids.

Determine whether the prescribed treatment was effective.

Answer 36

Determine whether the prescribed treatment was effective.

Question 37

Which statement best conveys the role of intuition in nurses’ problem solving?

Intuition is an unreliable mode of thinking that should be avoided.

Intuition is reliable when those nurses implementing it have a special “gift.”

Intuition can be a clinically useful adjunct to logical problem solving.

In experienced nurses, intuition can be a valid replacement for scientific problem solving.

Answer 37

Intuition can be a clinically useful adjunct to logical problem solving.

Question 38

A nurse has completed a client assessment and is preparing to identify appropriate nursing concerns. Which area(s) will the nurse likely address in the nursing concern? Select all that apply.

heart failure

pneumonia

altered mobility

altered nutrition

ineffective coping

Answer 38

altered mobility

altered nutrition

ineffective coping

Question 39

Avoiding information contrary to one’s opinion is an example of _____, an approach that leads to potential errors in clinical decision making.

Answer 39

Bias

Question 40

The outcome of critical thinking or clinical reasoning is known as clinical ____________, the conclusion, decision, or opinion the nurse makes.

Answer 40

Judgment

Question 41

Patient safety and transparency of information are two principles of ___________-centered care that can be used by every organization.

Answer 41

person

Question 42

T or F: Critical thinking is defined as “a systematic way to form and shape one’s thinking.”

Answer 42

True

Question 43

T or F: Clearly identifying patient strengths and actual and potential problems is a part of the nursing process known as assessing.

Answer 43

False

Question 44

Hypothesis formation and testing are two steps in the scientific problem-solving method used by health care professionals as they work with patients.

Answer 44

True

Question 45

Concept mapping—an instructional strategy to identify, graphically display and link key concepts—is an example of a critical-thinking approach to care planning.

Answer 45

True

Question 46

When the relationship between the carer and the cared for is used for promoting or restoring the health and well-being of people within the relationship, it becomes a _____________relationship.

Answer 46

therapeutic

Question 47

Problem solving that is ____________ refers to a direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible.

Answer 47

intuitive

Question 48

T or F: Twentieth-century health care in the United States has finally focused more on the needs of the patient rather than on the disease process affecting the patient.

Answer 48

False