NSG 100 Exam 1 Flashcards
A student nurse is studying clinical judgment theories and is working with Tanner’s Model of Clinical Judgment. How can the student nurse best generalize this model?
a. A reflective process where the nurse notices, interprets, responds and reflects in action
b. One conceptual mechanism for critiquing ideas and establishing goal-oriented care
c. Researching best practice literature to create care pathways for certain populations
d. Assessing, diagnosing, implementing, and evaluating the nursing care plans
a. A reflective process where the nurse notices, interprets, responds, and reflects in action
Rationale: Looking across theories and definitions of clinical judgment, they all have in common the ability to reflect on data and choose actions.
Reflection also considers evaluating the result of the actions to determine whether they were effective. Although critiquing ideas and establishing goal-oriented care could be considered part of a generalized statement of critical thinking, this is not broad enough without reflection and evaluation. Clinical judgment would most likely be used to create care paths derived from the evidence; however, this is not the cornerstone of the Tanner Model. Clinical judgment is used when engaging in the nursing process, but this is too narrow in focus to capture the essence of critical thinking definitions and theories. Critical thinking is not synonymous with the nursing process.
The nurse is implementing a plan of care for a patient newly diagnosed with type 2 diabetes mellitus. The plan includes educating the patient about diet choices. The patient states that they enjoy exercising and understand the need to diet; however, they can’t
see living without chocolate on a daily basis. Using the principles of responding in the Model of Clinical Judgment, how would the nurse proceed with the teaching?
a. The nurse explains to the patient that chocolate has a high glycemic index. The nurse then focuses on foods that have low glycemic indexes and provides a list for the patient to choose from.
b. The nurse explains that the patient may eat whatever they would like as long as the patient’s glucose reading and A1c remain stable.
c. The nurse derives a new nursing diagnosis of Knowledge Deficit and readjusts the plan of care to include additional sessions with the registered dietician.
d. The nurse examines the patient’s daily glucose log and incorporates the snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week.
d. The nurse examines the patient’s daily glucose log and incorporates the snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week.
Rationale: Responding entails adjusting the plan of care to the particular patient issue through one or more nursing interventions. In this case, the nurse is working with the patient’s wishes, knowing that the patient will most likely cheat. The patient will be allowed to “cheat.”
The plan will be evaluated to be sure the snack does not elevate the glucose excessively and be readjusted if warranted.
While it is true that most chocolate has a high glycemic index, providing a list of foods that do not include the one thing the patient enjoys will most likely lead to nonadherence to the diet. Advising the patient that they can have whatever they want to eat may lead to further dietary indiscretions and cause side effects such as obesity or high glucose readings.
Knowledge Deficit is an inaccurate diagnosis for this patient as evidenced by the patient stating they understand the need to exercise and the need to diet.
A new graduate nurse is working with an experienced nurse to chart assessment findings. The new nurse notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced
nurse asks the new nurse what may be going on here. What is the best explanation for this statement?
a. Data on the chart can sometimes be documented in a biased manner.
b. Data on the chart changes as the patient’s condition changes.
c. Data on the chart is usually accurate and can be verified by the patient.
d. Reading the chart is not a wise use of time as this can be time-consuming and tedious.
a. Data on the chart can sometimes be documented in a biased manner.
Rationale: It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record.
Data do indeed change (and need to be charted) as the patient’s condition changes, but this would not be the best answer to this question.
Assessment data may at times be difficult to obtain, but that would not occur often enough to warrant a warning about the difficulty in charting it. Also, obtaining data is clearly a different activity from charting it.
Charting can be time-consuming and tedious, but this is not the most complete answer to this question.
A home care nurse receives a physician order for a medication that the patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient’s condition, questions its appropriateness, and examines alternative treatments. What is the nurse’s best action?
a. Call the physician, explain the rationale, and suggest a different medication.
b. Consult an experienced nurse on whether there are other similar treatments.
c. Hold the drug until the physician returns to the unit and can be questioned.
d. Question other staff as to the physician’s acceptance of nursing input.
a. Call the physician, explain the rationale, and suggest a different medication.
Rationale: Determining how best to proceed on behalf of a patient’s best health outcomes care may require clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities have been examined.
A home care nurse who is using good clinical judgment techniques should have confidence in their decision and may not have another nurse available as this is an autonomous setting.
Holding the drug might jeopardize the patient’s health, so this is not the best solution.
The nurse working at this level of critical thinking makes choices based on careful examination of situations and alternatives; whether or not the physician is open to nursing input is not relevant.
A patient has been admitted for a skin graft following third-degree burns to the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, including home care and dressing changes. When should the nurse initiate the educational plan?
a. After the operation and the patient is awake
b. On admission, along with the initial assessment
c. The day before the patient is to be discharged
d. When narcotics are no longer needed routinely
b. On admission, along with the initial assessment
Rationale: Initial discharge planning begins upon admission.
After the operation has been completed is too late to begin the discharge planning process.
The day before discharge is too late for the nurse to gather all pertinent information and begin teaching and
coordinating resources.
After a complicated operation, the patient may well be discharged on narcotic analgesics. Waiting for the patient to not need them anymore might mean the patient gets discharged without teaching being done.
A nurse has designed an individualized nursing care plan for a patient, but the patient is not meeting goals. Further assessment reveals that the patient is not following through on many items. Which action by the nurse would be best for determining the cause of the problem?
a. Assess whether the actions were too hard for the patient.
b. Determine whether the patient agrees with the care plan.
c. Question the patient’s reasons for not following through.
d. Reevaluate data to ensure the diagnoses are sound.
b. Determine whether the patient agrees with the care plan.
Rationale: Having the patient and/or family provide input to the care plan is vital in order to gain support for the plan of action. The actions may have been too difficult for the patient, but this is a very narrow item to focus on.
The nurse might want to find out the rationale
for the patient not following through, but instead of directly questioning the patient, which can sound accusatory, it would be best to offer some possible motives.
Reevaluation should be an ongoing process, but the more likely cause of the patient’s failure to
follow-through is that the patient did not participate in making the plan of care.
A new nurse appears to be second-guessing herself and is constantly calling on the other nurses to double-check their plan of care or rehearse what they will say to the doctor before she calls on the patient’s behalf. This seems to be annoying some of the nurse’s coworkers. What is the nurse manager’s best response?
a. Explain to coworkers that this is a characteristic of critical thinking and is important for the new nurse to improve reasoning skills.
b. Agree with the staff and have someone follow and work more closely with a preceptor.
c. Have a talk with the nurse and suggest asking fewer questions.
d. Tell the staff that all new nurses go through this phase, and ignore their behavior.
a. Explain to coworkers that this is a characteristic of critical thinking and is important for the new nurse to improve reasoning skills.
Rationale: Reflection-on-action is critical for the development of knowledge and improvement in reasoning. It is where learning from practice is
incorporated into the experience. Inquisitiveness is a characteristic of critical thinking and reflects a desire to learn even when the knowledge may not appear readily useful. The manager should promote this. Suggesting the nurse work more closely with a
preceptor implies that the manager thinks the nurse needs to learn more and increase confidence. In reality, this nurse is demonstrating a characteristic of critical thinking.
Suggesting that the nurse ask fewer questions would hamper the development of the nurse as a critical thinker.
All new nurses do go through a phase of asking more questions at one time, but dismissing the nurse’s behavior with this explanation is simplistic and will discourage critical thinking
A nurse has committed a serious medication error and has reported the error to the hospital’s adverse medication error hotline as well as to the unit manager. The manager is a firm believer in developing critical thinking skills. From this standpoint, what action by the manager would best nurture this ability in the nurse who made the error?
a. Have the nurse present an in-service related to the cause of the error.
b. Instruct the nurse to write a paper on how to avoid this type of error.
c. Let the nurse work with more experienced nurses when giving medications.
d. Send the nurse to refresher courses on medication administration.
a. Have the nurse present an in-service related to the cause of the error.
Rationale: Nurturing critical thinking skills is done in part by turning errors into learning opportunities. If the nurse presents an in-service on the cause and prevention of the type of error committed, not only will the nurse learn something but many others nurses on the unit will learn from it too. This is the best example of developing critical thinking skills.
This option would allow the nurse to learn from the mistake, which is a method of developing critical thinking skills, but the paper would benefit only the nurse, so this option is not the best choice.
Letting the nurse work with more experienced nurses might be a good option in a very limited setting, for example, if the nurse is relatively new and the manager discovers a deficiency in the nurse’s orientation or training on giving medications in that system. Otherwise, this option would not really be beneficial. Sending the nurse to refresher courses might be a solution, but it is directed at the nurse’s learning, not critical thinking. The nurse might feel resentful at having to attend such classes, but even if they were helpful, only this one nurse is learning. Going to generic classes also does not address the specific reason this error occurred, and thus might be irrelevant. Critical thinking and learning can be enhanced by a presentation to the staff on the causes of the error.
A nurse is caring for a patient in a long-term care facility who has not been sleeping well. She notes that the patient is new to the facility, has been refusing therapy, and is also not eating well. The nurse interprets this to mean that the patient has been having trouble adjusting. The nurse decides to meet with the patient’s care team. The team decides to assess the patient’s willingness to participate in group recreational activities. The patient agrees to participate. After 1 week, the nurse reevaluates the plan of care and notes that the patient has been sleeping much better. Which of the following terms best describe processes used in the nurse’s plan? (Select all that apply.)
a. Clinical judgment
b. Evidence-based practice
c. The nursing process
d. Collaborative care planning
e. Positive reward process
a. Clinical judgment
c. The nursing process
d. Collaborative care planning
Rationale: Clinical judgment is a reflective process by which the nurse notices, interprets, responds, and reflects in action.
The nursing process is a process by which the nurse assesses, diagnoses, implements, and evaluates the nursing care plan.
Consulting and gaining input from the healthcare team is collaborative care planning.
Evidence-based practice refers to using interventions found in research studies.
The positive reward process is not a term used in care planning.
The nurse is reviewing the last 3 days of a patient’s pain history and notes that the pain level has remained constant. The nurse validates the pain level with the patient and decides to contact the provider for further orders. In this scenario, which process is the nurse is using?
a. Decision-making
b. Reasoning
c. Problem-solving
d. Judgment
d. Judgment
Rationale: Processes dependent on critical thinking include problem-solving, decision making, reasoning, and judgment. Judgment is the process of forming an opinion by comparing solutions through reasoning. The nurse observes that the patient’s pain level is not
decreasing and further assesses the pain level through discussions with the patient. The nurse concludes that the patient’s pain should be further addressed and contacts the provider. Decision-making requires choosing a solution to a problem. The student is
making a decision by reviewing two pertinent resources related to the removal of staples. Reasoning is the process by which a nurse links thoughts, ideas and facts together in a logical way. A systematic approach in finding solutions is termed problem
solving.
The nurse has been hired for a first job and is nervous about making errors in clinical judgment. It is important for the nurse to realize that clinical reasoning and the ability to make decisions in a clinical setting occurs at which time?
a. When it has been instilled in the content covered in nursing school.
b. When it is solely based in clinical experience.
c. When it develops over time with increased knowledge and expertise.
d. When it is an expectation of all nurses regardless of experience.
c. When it develops over time with increased knowledge and expertise.
Rationale: Clinical reasoning uses critical thinking, knowledge, and experience to develop solutions to problems and make decisions in a clinical setting. A nurse’s clinical-reasoning skills develop over time with increased knowledge and expertise.
The nurse is taking an advanced cardiac life support (ACLS) recertification class. As part of that class, the nurse and other nurses in the group rotate responsibilities during multiple mock code exercises simulating cardiac arrest scenarios. The nurse recognizes what process is assigning the nurses to these different responsibilities?
a. Concept mapping
b. Simulation
c. Role playing
d. Literature review
c. Role playing
Rationale: A role-play strategy involves assigning learners to different roles based on expected outcomes in a particular setting. Other learners
and facilitators observe the role-playing, and then all are involved in the debriefing or discussion of the scenario. As with simulation, this approach allows learners to interact in a safe, controlled environment. The concept map is a way to organize and visualize data to identify relationships and solve problems. Simulated experiences enable the student to apply previously learned content in a safe and realistic environment that allows time for questioning, clarifying, and feedback. Students develop confidence
in providing direct nursing care. Because critical thinking cannot occur about subjects that are unknown, a review of literature may foster this type of thinking by addressing knowledge deficits.
The nurse is preparing to administer an anticoagulant when the patient says, “Why do I have these bruises on my arms?” The nurse reviews the patient’s blood tests and notes an abnormal bleeding time. When the nurse then decides to hold the medication and notify the health care provider, the nurse recognizes this to be an example of which action?
a. Thinking aloud
b. Reviewing the literature
c. Applying knowledge
d. Role playing
c. Applying knowledge
Rationale: Nursing practice is based on the application of knowledge to address patient problems. In this case, the nurse is able to connect the medication, physical signs and laboratory data to determine a course of action. Nurses may “think aloud” as an inner dialogue to examine their thinking. The literature review is used to address knowledge gaps through the review of scholarly journals. A role-play strategy involves assigning learners to different roles based on expected outcomes in a particular setting. Other learners and facilitators observe the role-playing, and then all are involved in the debriefing or discussion of the scenario.
The nurse is preparing to restart a patient’s intravenous line and discovers that the patient has no usable veins in either arm. When working to solve this problem, the nurse should carry out which action?
a. Discuss the problem with the nurse in charge.
b. Not start the intravenous line.
c. Conduct an Internet search for infusion journal articles.
d. Contact the provider and report the concern.
a. Discuss the problem with the nurse in charge.
Rationale: Whether in an academic setting or in the clinical area, discussion of a problem, issue, or situation with colleagues may improve critical thinking. Through dialogue with others who have expertise or experience with the issue being faced, knowledge gaps can be filled, erroneous assumptions exposed, and unconscious biases addressed. Not starting the intravenous line is not an option at this point. A literature review to gain published information about intravenous complications may be appropriate after the patient’s concern has been addressed. Initially contacting the provider without fully exploring the options for alternate insertion sites is neither wise nor recommended.
The nurse has finished a shift and is on the way home. During the shift, one of the patients attempted to climb out of bed and fell. When the nurse is returning home and is thinking about what could have been done differently to prevent the fall, this would be an example of what concept?
a. Evidence
b. Standards
c. Attributes or traits
d. Reflection
d. Reflection
Rationale: A reflection is an effective tool that enables students and nurses to think about how best to improve their future caregiving in similar situations. The results of deliberate thinking are used to guide further thinking. Identification and use of evidence is necessary to guide analysis of situations and decision making. Nursing practice must be based on evidence gained through research and review of findings. Some personal characteristics are associated with critical thinking. Critical thinking needs to be assessed and evaluated according to standards to ensure the quality of thinking. Nursing practice is based on standards established by the American Nurses Association in areas such as the nursing process, ethics, education, research, communication, leadership, and collaboration.
When working on the ability to critically think, the nurse needs to develop a critical-thinking character that includes which quality?
a. Developing honesty and confidence
b. Learning from experiences
c. Enhancing self-reliance
d. Growing a “thick skin” to withstand criticism
a. Developing honesty and confidence
Rationale: To develop critical thinking, the nurse needs to develop a critical-thinking character, which includes maintaining high standards and developing critical-thinking qualities such as honesty, fair-mindedness, creativity, patience, persistence, and confidence. The
next step in the development of critical thinking includes taking responsibility for personal learning and seeking needed experiences that can provide the necessary knowledge on which to base the thinking. Fostering interpersonal skills, such as teamwork, conflict management, and advocacy, is important in the development of critical thinking. Self-evaluation and having thinking evaluated by others require the ability to accept and use constructive criticism.
A patient arrives at the urgent care clinic and complains of vague pains in the legs and the nurse asks the patient to describe this pain in greater depth. The nurse knows this is a critical-thinking skill and can be developed in which context?
a. Critical thinking is used to avoid repetition in providing care.
b. Critical thinking can be enhanced through practice.
c. Critical thinking should be based in thought and not spontaneity.
d. Critical-thinking skills become dull when used routinely.
b. Critical thinking can be enhanced through practice.
Rationale: The ultimate goal is for these questions to become so spontaneous in thinking that they form a natural part of our inner voice, guiding us to better reasoning. As with any skill, critical thinking can be enhanced through practice. The routine use of these
questions should promote critical thought.
The nurse is planning care for a group of patients and recognizes which activity may be delegated to unlicensed assistive personnel?
a. Analysis of the patient’s physical condition
b. Morning vital signs, height, and weight
c. Evaluation of whether colostomy drainage is normal
d. Determining patient readiness for post-surgical learning
b. Morning vital signs, height, and weight
Rationale: The nurse often works with unlicensed assistive personnel (UAP) to collect relevant data on height and weight, intake and output, and vital signs. The registered nurse uses critical thinking to guide decisions related to delegation of assignments and tasks. Before delegation of a task, the nurse must be knowledgeable about the role, scope of practice, and competency of the recipient of the delegated task. Analysis and evaluation of patient conditions and readiness for teaching require critical thinking and are nursing functions.
The nurse is preparing to teach indwelling urinary catheter insertion techniques to a group of graduate nurses. Which teaching-learning strategy would the nurse find most useful in teaching this skill?
a. Concept mapping
b. Simulation
c. Role playing
d. Literature review
b. Simulation
Rationale: Simulated experiences enable the student to apply previously learned content in a safe and realistic environment that allows time for questioning, clarifying, and feedback. Students develop confidence in providing direct nursing care. The concept map as a way to organize and visualize data to identify relationships and solve problems.
Role-play strategies involve assigning learners to different roles based on expected outcomes in a particular setting. Other learners and facilitators observe the role-playing, and then all are involved in the debriefing or discussion of the scenario.
As with simulation, this approach allows learners to interact in a safe, controlled environment. Because critical thinking cannot occur about subjects that are unknown, a review of literature may foster this type of thinking by addressing knowledge deficits.
The nurse is administering medications to a patient with high blood pressure. The patient states, “This pill made me so sick yesterday. Are you sure I have to take it now?” What action does the nurse take next?
a. Give the medication because no one gets sick on this pill.
b. Hold the medication and check the order since there may be a lack of information.
c. Give the medication since he/she is the nurse and knows what should be done.
d. Give the medication since the nurse did not see the provider come so the order is valid.
b. Hold the medication and check the order since there may be a lack of information.
Rationale: Errors in thinking can lead to errors in nursing care. It is essential for the nurse to assess and validate the patient’s concerns before proceeding with planned action. This helps avoid decisions being made on personal biases caused by preconceived notions. The nurse should hold the medication and investigate further. Believing that “no one gets sick on this pill” is a preconceived bias.
Giving the medication because “I know best” is an example of close-mindedness. Assuming the order is valid simply because the nurse did not see the provider is illogical thinking.
The nurse recognizes that when a patient is initially interviewed and assessed, the nurse must complete which tasks? (Select all that apply.)
a. Analyze the patient’s psychomotor status.
b. Take the patient’s vital signs.
c. Weigh the patient using a bed scale.
d. Evaluate the patient’s emotional and spiritual needs.
e. Ensure the coordination of the patient’s care.
a. Analyze the patient’s psychomotor status.
d. Evaluate the patient’s emotional and spiritual needs.
e. Ensure the coordination of the patient’s care.
Rationale: When a patient is initially interviewed and assessed, the nurse must complete a thorough analysis of the patient’s physical, emotional, spiritual, and psychomotor status. The nurse often works with unlicensed assistive personnel (UAP) to collect relevant
data on height and weight, intake and output, and vital signs. Nurses collaborate with other health care professionals to coordinate care. Interdisciplinary clinical rounds, which include physicians, registered nurses, physical therapists, occupational therapists, and dietitians, are often undertaken to identify priorities of care, discuss overlapping areas of treatment, and ensure coordination of care.
The nurse knows that professional nursing requires a commitment to which reasons for lifelong learning? (Select all that apply.)
a. Treatment modalities and technology continue to advance.
b. There are always new things to memorize and store in memory.
c. Nurses are expected to update and maintain competency.
d. Critical thinking is essential in nursing.
e. Nursing school gives the nurse all one needs to be competent.
a. Treatment modalities and technology continue to advance.
c. Nurses are expected to update and maintain competency.
d. Critical thinking is essential in nursing.
Rationale: Professional nursing requires a commitment to lifelong learning. Nurses must possess critical-thinking skills to maintain pace with ever-changing treatment modalities and technological advances. Outdated learning strategies that focus on remembering content must be replaced by a focus on understanding the rationales and outcomes. It is an expectation of professional practice that nurses
update and maintain their competency and knowledge base. The increasing complexity of health care and information technology make critical thinking essential in nursing. No longer is rote memorization and recall of content sufficient for the complex decisions and judgment required in professional nursing practice. Because knowledge and technology continue to expand for nursing professionals, the content learned in nursing school is not sufficient to maintain competence in nursing practice.
The nurse has been practicing for several years and has become an unofficial leader, with newer nurses asking for advice about patient care. They are amazed at how much the older nurse “thinks like a nurse.” To “think like a nurse,” the nurse must carry out
which actions? (Select all that apply.)
a. Be a nurse for several years.
b. Be able to apply knowledge in making clinical decisions.
c. Actively participate in the process.
d. Accept procedures that have been in place for years as right.
e. Develop a questioning attitude.
b. Be able to apply knowledge in making clinical decisions.
c. Actively participate in the process.
e. Develop a questioning attitude.
Rationale: Because nursing requires the application of knowledge to make clinical decisions and guide care, it involves active participation by the nurse. The application of knowledge requires the development of a questioning attitude. This process is sometimes referred to as thinking like a nurse. “Several years” is vague, and nurses develop critical thinking abilities at different rates. A questioning attitude does not accept doing things because they have been done that way for a long time.
The nurse identifies the nursing process as the foundation of professional nursing practice and can define it in which appropriate terms?
a. The framework that nurses use to provide care.
b. A complex process during which nurses think about their thinking.
c. The process that allows nurses to collect essential data.
d. Thinking like a nurse in developing plans of care.
a. The framework that nurses use to provide care.
Rationale: The nursing process is the foundation of professional nursing practice. It is the framework within which nurses provide care to patients in an organized and effective manner.
Paul describes critical thinking as a complex process during which individuals think about their thinking to provide clarity and increase precision and relevance in a specific situation while attempting to be fair and consistent.
Critical thinking using the nursing process allows nurses to collect essential patient data, articulate the specific needs of individual patients, and effectively communicate those needs, realistic goals, and customized interventions with members of the health care team.
Thinking like a nurse is facilitated by nurses using the nursing process in the development of individualized patient plans of care.
Since the nursing process is cyclic rather than linear, the nurse knows that as an individual patient’s condition changes the nurse should anticipate what concept?
a. The nurse’s thought processes do not have to vary.
b. Plans of care are easier to use and do not need modification.
c. The accuracy and effectiveness of thought processes must be considered.
d. Reflective thought is not necessary since issues tend to be repetitive.
c. The accuracy and effectiveness of thought processes must be considered.
Rationale: The nursing process is cyclic rather than linear. As an individual patient’s condition changes, so does the way a professional nurse thinks about that patient’s needs, forcing modification of earlier plans of care. At each step of the nursing process, nurses must
consider the accuracy and effectiveness of their thought process. This form of reflective thought is an essential aspect of critical thinking. The evolutionary nature of the nursing process allows nurses to adjust to changing patient needs. Plans of care must evolve as patients’ needs change.
The charge nurse is discussing a patient’s care plan during a team meeting. The team determines that the patient has not met the
goal of “ambulating to the nurse’s station twice a day” and decides to revise the plan. The nurse recognizes which characteristic of
the nursing process most represents this decision?
a. Organization
b. Dynamics
c. Adaptability
d. Outcome orientation
d. Outcome orientation
The nurse is caring for a patient who will be discharged home following surgical repair of a broken shoulder. The patient tells the nurse, “I don’t have anyone at home who can help me cook my meals. Is there something you can do?” When demonstrating the adaptability of the nursing process, the nurse should carry out which task?
a. Adjust the patient’s care plan so that nursing goals can be met.
b. Consult the care provider about extending the patient’s hospitalization.
c. Abandon the plan of care as not able to be done.
d. Contact the social worker about community services.
d. Contact the social worker about community services.
Rationale: The nursing process is adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. The nurse would adjust planning to contact the social worker for community resources so the patient can maintain as much independence as possible. The care plan focuses on the patient’s goals. The provider may or
may not be able to extend the hospital stay, but even if that were possible, the patient would not be able to stay until all function returned. The nurse does not simply abandon the care plan; the nurse looks for options and adaptations.
The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The nurse recognizes that the health history is conducted in which step of the nursing process?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation
a. Assessment
Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in
standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers.
The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse is assisting a patient to bed when the patient says, “My chest hurts and my left arm feels numb. What’s wrong with me?”
What is the type and source of data obtained from the patient’s complaint?
a. Objective data from a primary source
b. Objective data from a secondary source
c. Subjective data from a primary source
d. Subjective data from a secondary source
c. Subjective data from a primary source
Rationale: Objective data consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested.
Subjective data are spoken. Primary data consist of information obtained directly from a patient. Secondary data are collected from family members, friends, other health care professionals, or written sources such as medical records and test results.
The nurse identifies which statement to be a correctly written Nursing diagnosis appropriate for a patient’s plan of care?
a. Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds.
b. Imbalanced nutrition: less than body requirements.
c. Impaired physical mobility related to contractures.
d. Risk for suffocation related to smoking in bed as evidenced by absent breath sounds.
a. Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds.
Rationale: There are three types of diagnoses: actual, risk, and opportunities for improvement. Actual diagnoses have three parts: problem, etiology, and signs/symptoms. Risk diagnoses include only the identified need and the risk factors. The Nursing diagnosis, imbalanced nutrition: less than body requirements, is missing the problem, etiology, and signs and symptoms. Impaired physical mobility is missing the evidence. Risk for suffocation should have only two parts: the potential problem and etiology. There are no signs and symptoms if the patient is at risk.
The nurse is admitting a patient experiencing chest discomfort and shortness of breath, who has a history of stroke. When the nurse documents the Nursing diagnosis “Risk for impaired mobility related to history of stroke,” the nurse knows which condition to be
the risk factor?
a. Stroke
b. History of stroke
c. Chest discomfort
d. Shortness of breath
b. History of stroke
Rationale: A two-part risk, Nursing diagnostic statement contains only: (1) the patient’s identified need or problem (i.e., NANDA-I Nursing diagnostic label) and (2) factors indicating vulnerability (i.e., risk factors). The risk factor is the history of stroke. The chest
discomfort and shortness of breath are symptoms of the current problems and would not be documented as potential or “risk” issues. “Stroke” would be the identified potential problem.
A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
a. Assessment
Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient-focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes.
In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
While the nurse is assisting with morning care, the patient has a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
c. Implementation
Rationale: The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and
physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient-focused, with specific outcome identification for evaluation
purposes. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse is caring for a patient diagnosed with Lyme disease. The patient tells the nurse, “My heart seems to be skipping some beats. My doctor told me to let the nurse know if this happens since it might be a complication of my disease.” The nurse auscultates the heart and confirms the palpitations. Which step of the nursing process does the nurse’s action demonstrate?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
a. Assessment
Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient-focused, with specific outcome identification for evaluation purposes. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes.
In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
In which step of the nursing process does the nurse prioritize the Nursing diagnoses and identify interventions to address the patient goals?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
b. Planning
Rationale: During the planning step of the nursing process, the nurse prioritizes the Nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes.
In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse writes a short-term goal for a patient scheduled for surgery in the morning and identifies which goal that contains all the necessary elements?
a. The patient will walk to the bathroom within 48 hours after surgery.
b. The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery.
c. The patient will walk to the bathroom without experiencing shortness of breath.
d. The patient will walk to the bathroom without experiencing shortness of breath after surgery.
b. The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery.
Rationale: All short- and long-term goals must be: (1) patient-focused, (2) realistic, and (3) measurable. For example, a patient-focused, realistic, and measurable short-term goal may be written for a patient with the Nursing diagnosis of Activity intolerance: The patient walks to the bathroom without experiencing shortness of breath within 48 hours after surgery.
A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. When the nurse asks the manager if there is a document written by the physician for this type of reaction, the nurse is referring to which concept?
a. Protocol
b. Clinical pathway
c. Standing order
d. Care map
c. Standing order
Rationale: Standing orders are written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when care is common to a certain type of situation, such as what to do if a patient experiences chest pain or what actions to take after a colonoscopy. Protocols are written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician’s order. Health care agencies have established protocols outlining procedures for admitting patients or handling routine care situations. Clinical pathways, sometimes referred to as care pathways, care maps, or critical pathways, are multidisciplinary resources designed to guide patient care.
All nursing interventions that are implemented for patients must be documented or charted. The nurse knows that proper documentation of interventions leads to what positive outcome?
a. Proper documentation facilitates communication with all members of the health care team.
b. Proper documentation is only considered “legal” if documented in the paper chart.
c. Proper documentation prevents errors of omission and repetition of care.
d. Proper documentation does not directly measure goal achievement or outcomes.
a. Proper documentation facilitates communication with all members of the health care team.
Rationale: All nursing interventions that are implemented for patients must be documented or charted. In some cases, this may involve checking off an intervention in the patient’s EMR designed to track the effectiveness of specific interventions. Many health care agencies have special requirements for documenting interventions such as the use of physical restraints or pain protocols. Proper documentation of interventions facilitates communication with all members of the health care team and provides an essential legal record. Accurate charting helps to alleviate omissions and repetition of care although it cannot prevent them. Documentation also
allows nurses to evaluate the effectiveness of nursing interventions in meeting patient goals and outcomes, which is the final step in the nursing process.
The nurse makes the following entry on the patient’s care plan: “Goal not met. Patient refuses to walk and states, ‘I’m afraid of falling.’” The nurse should complete which next action?
a. Ignore the patient’s concern in evaluating goal attainment.
b. Document the patient’s unwillingness to continue the plan of care.
c. Continue the plan of care as originally agreed upon.
d. Modify the care plan in response to the patient’s condition and wishes.
d. Modify the care plan in response to the patient’s condition and wishes.
Rationale: Evaluation focuses on the patient and the patient’s response to nursing interventions and goal or outcome attainment. If a goal was not met, the care plan needs to be modified to avoid simply repeating the same actions. Ignoring the patient is not a therapeutic response. The nurse should respect the patient’s fear and assess further without simply documenting that the patient is unwilling.
The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing?
a. Assessment
b. Diagnosis
c. Implementation
d. Evaluation
c. Implementation
Rationale: The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. During the assessment step, patient care data are gathered through observation, interviews, and
physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse develops a list of Nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, “I understand that I will lose most of my hair. Will it grow back?” The nurse identifies which diagnosis will have the highest priority?
a. Disturbed body image
b. Nausea
c. Risk for bleeding
d. Imbalanced nutrition: less than body requirements
a. Disturbed body image
Rationale: Priority of Nursing diagnoses is determined by the patient’s preference as well as the severity of the symptoms. The patient is concerned about the loss of hair because this will affect body image. For the patient, this is a prime focus. It is possible that the
patient may experience nausea as a result of the chemotherapy drugs. The patient will not be able to eat properly if the nausea is not controlled thus decreasing nutritional intake. There is a potential for bleeding as a result of the low platelet count created by the
drugs. All of these must be addressed, but the primary diagnosis, in this case, would be body image.
The nurse is gathering data on a patient with acute bacterial pneumonia. The nurse recognizes that this is an example of which step of the nursing process?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
a. Assessment
Rationale: During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in
standardized language as a specific Nursing diagnosis to provide greater clarity and universal understanding by all care providers.
The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient’s goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse knows which statements would be considered objective data? (Select all that apply.)
a. “I’m short of breath.”
b. “Blood pressure 90/68, apical pulse 102, skin pale and moist.”
c. “Lung sounds clear bilaterally, diminished in right lower lobe.”
d. “I feel weak all over when I exert myself.”
e. “My pain level is down to 2. It was 8.”
b. “Blood pressure 90/68, apical pulse 102, skin pale and moist.”
c. “Lung sounds clear bilaterally, diminished in right lower lobe.”
Rationale: Data collected from medical records, laboratory, and diagnostic test results, or physical assessments are objective. Objective data
(i.e., signs) consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested.
Subjective data (i.e., symptoms) are spoken. Patients’ feelings about a situation or comments about how they are feeling are examples of subjective data. Data shared by a source verbally are considered subjective. Subjective data may be difficult to validate
because they cannot be independently and objectively measured.
The nurse is attempting to develop Nursing diagnoses for a patient. The nurse understands that Nursing diagnoses have which characteristics? (Select all that apply.)
a. Nursing diagnoses identify actual or potential problems as well as responses to a problem.
b. Nursing diagnoses require naming patient problems using Nursing diagnostic labels.
c. Nursing diagnoses utilize objective data since subjective data are often inaccurate.
d. Nursing diagnoses include unvalidated data to determine an accurate and thorough diagnosis.
e. Nursing diagnoses are similar to medical diagnoses since they both are labels for diseases.
a. Nursing diagnoses identify actual or potential problems as well as responses to a problem.
b. Nursing diagnoses require naming patient problems using Nursing diagnostic labels.
Rationale: The Nursing diagnosis identifies an actual or potential problem or response to a problem. Accurate identification of Nursing diagnoses for patients results from carefully analyzing, validating, and clustering related patient subjective (symptoms) and
objective (signs) data. If data collection includes inaccurate or inadequate information or if data are not validated or clustered with related information, a patient may be misdiagnosed. Diagnosis in the nursing process requires naming patient problems using
Nursing diagnostic labels. Medical diagnoses are labels for diseases, whereas Nursing diagnoses describe a response to an actual or potential problem or life process.
The nurse recognizes that establishing short- and long-term goals to address Nursing diagnoses involve which actions? (Select all that apply.)
a. Discussion with the patient
b. Exclusion of family with making patient decisions
c. Collaboration with other members of health care team
d. Making the health care provider as the central figure
e. Coordination of care as collaborative care
a. Discussion with the patient
c. Collaboration with other members of health care team
e. Coordination of care as collaborative care
Rationale: Establishing short- and long-term goals to address Nursing diagnoses involves discussion with the patient and often requires collaboration with family members and other members of the health care team. Coordinated, team-based patient care is called
collaborative care. The patient’s health care team members may include several nurses: the primary care provider; medical or surgical specialists; respiratory therapists; a dietitian; a physical therapist; occupational, music, or art therapists; a spiritual adviser; and social workers. The patient’s primary nurse is often the central figure in coordinating collaborative care.
The nurse is caring for a patient with pneumonia, who is a retired soldier who served in World War II. With this information in mind, what should the nurse do in regarding this patient?
a. Shake the patient’s hand and allow the patient time to “warm up.”
b. Expect the patient to be optimistic and question everything.
c. Allow the patient to multitask and talk in short “sound bites.”
d. Understand that the patient is probably technologically literate.
a. Shake the patient’s hand and allow the patient time to “warm-up.”
Rationale: Establishing rapport is paramount to gaining the trust of the patient. The nurse should consider the patient’s generational cohort, which may influence behavior, and willingness to share personal information during the interview process.
Veterans (born before 1945) respect authority; are detail-oriented; communicate in a discrete, formal, respectful way; may be slow to warm up; value family and community and accept physical touch as an effective form of therapeutic communication.
Baby Boomers (born 1946 to 1964) are optimistic, relationship-oriented, and communicate by using open or direct speech, using body language, and answering questions thoroughly. They expect detailed information, question everything, and value success. Generation X members (born 1965 to 1976) are informal; are technology immigrants; multitask; communicate in a blunt or direct, factual, and informal style; may talk in short sound bites; share information frequently; and value time.
Millennials, also called Generation Y (born 1977 to 1994) are flexible; are technologically literate or are technology natives; multitask; communicate by using action verbs and humor; may be brief in the form of texting or e-mail exchanges; like personal attention; and value individuality.
Individuals from Generation Z (born 1995 to 2012) are digitally connected, value group work, want immediate feedback, are accepting of others, value honesty, and family, and are entrepreneurial.
The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of a patient interview, the
nurse carries out what action?
a. Obtain demographic data using open-ended questions.
b. Establish the name by which the patient prefers to be addressed.
c. Gather general information using closed-ended questions.
d. Stand by the bedside to ask the needed questions.
b. Establish the name by which the patient prefers to be addressed.
Rationale: The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient.
During the orientation phase of the interview, the nurse should establish the name by which the patient prefers to be addressed. Some individuals prefer formal titles of respect (e.g., Dr., Mr., Ms., Professor) and the use of surnames, whereas others are comfortable with less formality.
How a patient is addressed is the patient’s choice. Demographic data should be collected by asking focused or closed-ended questions.
More general information can be gathered by open-ended communication techniques. When feasible, the nurse and the patient should be seated at eye level with
each other. In this way, the interaction between the nurse and the patient is horizontal instead of vertical. Standing over someone implies control, power, and authority.
The implication of power can result in less-than-optimal data collection and a potential conflict as the patient strives to regain control over the situation.
A nurse is conducting a health interview on a newly admitted patient. To establish a trusting relationship with the patient, the nurse carries out which action?
a. Avoid eye contact to appear less threatening.
b. Demonstrate professionalism by not smiling.
c. Sit close and leans in slightly toward the patient.
d. Speaks in a slow rate of speech and low tone.
c. Sit close and leans in slightly toward the patient.
Rationale: Nonverbal behaviors of the nurse can influence the information obtained from the patient. Negative nonverbal cues such as distracting gestures (e.g., tapping a pen, swinging a foot, looking at a watch), inappropriate facial expressions, and lack of eye contact communicate disinterest.
To establish a trusting relationship with the patient before the physical examination is conducted, the nurse should communicate professionally, sit close and lean in slightly toward the patient, listen attentively and demonstrate appropriate eye contact, smile, and use a moderate rate of speech and tone of voice.
The nurse is assigned the admission health history and physical for a patient diagnosed with a fever of unknown etiology. The patient tells the nurse, “I just don’t feel good. I’m so hot and I feel sick to my stomach. Can you ask me those questions later?”
What would be the best response by the nurse?
a. “It will not take too long. I can hurry.”
b. “We need the information to complete your admission paperwork.”
c. “I will come back in a few minutes and we can start over.”
d. “Let me see if you can have something for the nausea and then talk later.”
d. “Let me see if you can have something for the nausea and then talk later.”
Rationale: If a patient being admitted to the hospital is too ill to interact for an extended period, the interview can be broken into smaller segments. Interviews with patients already hospitalized or established in the health care system are less extensive and more focused
on newly identified patient concerns or problems. Ensuring that the patient is comfortable and relaxed is a priority and often takes prior thought and planning by the nurse.
The nurse is using a stethoscope to assess a patient’s cardiac status. Which assessment technique is the nurse using?
a. Inspection
b. Percussion
c. Palpation
d. Auscultation
d. Auscultation
Rationale: Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity.
Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems.
Percussion involves tapping the patient’s skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures. Vibration is reflected
by the tissues, and the character of the sound heard depends on the density of the structures that reflect the sound.
Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness.
The nurse is performing an assessment of a patient’s right kidney. The nurse bluntly strikes the area of the costovertebral angle while observing the patient’s reaction. Which assessment technique is the nurse using?
a. Inspection
b. Percussion
c. Palpation
d. Auscultation
b. Percussion
Rationale: Percussion involves tapping the patient’s skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures.
Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems.
Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness.
Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Vibration is reflected by the tissues, and the character of the sound heard depends on the density of the structures that reflect the sound.
The nurse is performing a physical exam on a patient diagnosed with liver failure resulting from chronic alcoholism. The nurse notes that the abdomen is swollen and decides to assess for abdominal skin tenderness and temperature. Which technique would the nurse use to collect this data?
a. Inspection
b. Percussion
c. Palpation
d. Auscultation
c. Palpation
Rationale: Palpation uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness.
Inspection involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body systems.
Percussion involves tapping the patient’s skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures.
Auscultation is a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity. Vibration is reflected by the
tissues and the character of the sound heard depends on the density of the structures that reflect the sound.
The triage nurse in a hospital emergency department is determining the order of care for several patients. Which patient would the nurse consider as having the highest priority?
a. A 68-year-old patient suffering from dehydration and disorientation
b. A 14-year-old patient having respiratory distress and increasing anxiety
c. A 46-year-old patient with multiple cuts and abrasions to the upper extremities
d. A 38-year-old patient with a broken right hip and in severe pain
b. A 14-year-old patient having respiratory distress and increasing anxiety
Rationale: Triage, a form of emergency assessment, is the classification of patients according to treatment priority. Patients are categorized by the urgency of their condition. Most emergency departments use a five-tier triage system. The five-tier system classifies patients by levels numbered 1 through 5.
Level 1 is considered critical: life-threatening conditions require immediate and continuous care such as severe trauma, cardiac arrest, respiratory distress, seizure, or shock.
Level 2 emergencies can be imminently life-threatening conditions requiring care within 30 minutes, such as chest pain or major fractures, with severe pain.
Level 3 is considered urgent: potentially life-threatening conditions that require care within 30 to 60 minutes, such as minor fractures, lacerations, and
dehydration.
Level 4 is considered semi-urgent, stable health conditions that require care within 60 to 120 minutes, such as a twisted ankle.
Level 5 conditions are non-urgent and lower risk such as cold symptoms.
The morning nurse is assigned to care for a patient admitted during the night with rectal bleeding. When making rounds, the nurse observes that the patient’s face is ashen in color and the skin is cool and clammy. The nurse auscultates the patient’s heart and lungs. Which category of physical assessment is the basis for the nurse’s response?
a. Emergency assessment
b. Focused assessment
c. Complete assessment
d. Initial comprehensive
a. Emergency assessment
Rationale: Emergency assessment is a physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes. Attention is paid to the patient’s airway, breathing, and circulation. Other concerns in the emergent setting are noticeable deformities such as compound fractures, contusions, abrasions, puncture wounds, burns, tenderness, lacerations, bleeding, and swelling. During an emergency, the nurse may never have time to do a complete assessment and may work to stabilize one body system at a time.
A focused or clinical assessment is a brief individualized physical examination conducted at the beginning of an acute care setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern. A focused assessment may be conducted when signs indicate a change in a patient’s condition or the development of a new complication.
A comprehensive or complete assessment includes a thorough interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves and sensory organs, such as with sight and hearing testing.
A complete physical examination may be conducted on admission to a hospital, during an annual physical at the office of a physician or nurse practitioner, or on initial interaction with a specialist.
The nurse is performing her initial assessment of the day when she notices that the patient has a facial droop that was not present yesterday and that was not reported in the hand-off report from the night nurse. The nurse proceeds to assess the neurologic status
of the patient and knows this to be which type of assessment?
a. Emergency assessment
b. Focused assessment
c. Complete physical examination
d. Comprehensive assessment
b. Focused assessment
Rationale: A focused or clinical assessment is a brief individualized physical examination conducted at the beginning of an acute care setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern.
A focused assessment may be conducted when signs indicate a change in a patient’s condition or the development of a new complication. Emergency assessment is a physical examination done when time is a factor, treatment must begin immediately, or
priorities for care need to be established in a few seconds or minutes. Attention is paid to the patient’s airway, breathing, and circulation. Other concerns in the emergent setting are noticeable deformities such as compound fractures, contusions, abrasions,
puncture wounds, burns, tenderness, lacerations, bleeding, and swelling.
A comprehensive or complete assessment includes a thorough interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves and sensory organs, such as with sight and hearing testing.
A complete physical examination may be conducted on
admission to a hospital, during an annual physical at the office of a physician or nurse practitioner, or on initial interaction with a specialist
The nurse is documenting data collected during a health assessment interview. Which statement by the nurse indicates subjective data?
a. “My last bowel movement was 4 days ago.”
b. Abdomen distended; firm and tender.
c. Dark-colored; hard pellet-shaped stool.
d. Color pink. Skin warm and dry. No sign of discomfort.
a. “My last bowel movement was 4 days ago.”
Rationale: Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms. Objective data, also referred to as signs, can be measured or observed. The nurse’s senses of sight, hearing, touch, and smell are used to collect objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results.
A patient is transported to the emergency department from a local skilled nursing facility and admitted for a bacterial blood infection. The nurse reviews the transferring physician notes, which indicate that the patient has dementia. The nurse contacts the
patient’s son for additional health history information. Information provided by the son would be considered which type of data?
a. Primary, objective data
b. Primary, subjective data
c. Secondary, objective data
d. Secondary, subjective data
d. Secondary, subjective data
Rationale: Subjective data are spoken information or symptoms that cannot be authenticated. Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms. Family members, friends, and other members of the
health care team can contribute valid secondary, subjective data.
Objective data also referred to as signs, can be measured or observed. The nurse’s senses of sight, hearing, touch, and smell are used to collect objective data.
Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results. Primary data come directly from the patient.
The nurse is monitoring the blood sugar results of a patient receiving an intravenous nutritional supplement. The patient tells the nurse, “I have never had sugar problems before. My doctor says it is because I am getting this IV.” These types of data are
considered to be which type?
a. Primary, objective data
b. Primary, subjective data
c. Secondary, objective data
d. Secondary, subjective data
b. Primary, subjective data
Rationale: Primary data come directly from the patient. Subjective data are spoken information or symptoms that cannot be authenticated.
Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms. Family members, friends, and other members of the health care team can contribute valid secondary, subjective data.
Objective data also referred to as signs, can be measured or observed. The nurse’s senses of sight, hearing, touch, and smell are used to collect
objective data. Objective assessment data are acquired through observation, physical examination, and analysis of laboratory and diagnostic test results.
The unlicensed nursing assistive person (UAP) reports to the nurse that a patient is crying during a comedy show on television.
What would be the best response by the nurse?
a. “Maybe the patient doesn’t think the show is funny.”
b. “Don’t worry about it. The patient’s daughter says this is normal.”
c. “I will go visit her right away and see what is going on.”
d. “Just document what you observe in your notes.”
c. “I will go visit her right away and see what is going on.”
Rationale: Validating data is making sure that the data are accurate. As patient information is collected, consistency between subjective and objective data must be confirmed. Confirming the validity of collected data often requires verbally checking with the patient to see whether the assumptions or conclusions at which the nurse arrived are correct. Crying, a disheveled appearance and lack of eye contact may be cues of depression. However, conclusions about the underlying cause of the patient’s actions cannot be assumed.
All cues need to be interpreted and validated to verify the data’s accuracy. The nurse cannot assume that this is normal behavior nor ignore the problem by making a joke. The nurse has the responsibility to attempt to determine the real reason for the crying episode.
A patient with moderate lower back pain tells the nurse, “My urine smells awful and is as dark as my glass of tea.” Which action by the nurse will assist in validating the patient’s concern?
a. Ask the patient to describe the back pain.
b. Review the lab results of the most recent urinalysis.
c. Request the nursing assistant to obtain a set of vital signs.
d. Check the patient’s history for urinary tract infections.
b. Review the lab results of the most recent urinalysis.
Rationale: As patient information is collected, consistency between subjective and objective data must be confirmed. Sometimes, the nurse
can use laboratory and diagnostic test results to validate the subjective data. In this case, checking the urinalysis for congruency with the patient’s subjective data will validate the patient’s statements. Obtaining a set of vital signs, reviewing the patient’s history, and exploring the patient’s pain are appropriate actions but cannot validate the current problem.
The nurse is attempting to get the patient to sign the operative consent. When asked if the health care provider explained the procedure to the patient, the patient replies “Not much.” What action will the nurse take next?
a. Develop a comprehensive teaching plan related to the surgical procedure.
b. Ask the patient what information the surgeon has explained about the surgery.
c. Contact the surgeon to clarify information given to the patient.
d. Focus on post-operative exercises and home-care following surgery.
b. Ask the patient what information the surgeon has explained about the surgery.
Rationale: Careful observation and attention to detail help the nurse to notice subtle cues and recognize how best to validate and interpret patient data. The nurse must be careful not to make false assumptions or generalizations regarding the patient’s responses to the health concern. The nurse is correct to ask the patient about the upcoming surgical procedure instead of assuming that the patient has limited knowledge. This is the nurse’s best action to determine what the surgeon said to the patient. Developing a
comprehensive teaching plan is not necessary until further clarification is obtained. Focusing on postoperative treatment plans is important but not the priority at this time. It is not appropriate to contact the surgeon unless the patient demonstrates an actual
knowledge deficit.
After the patient’s data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. What is the framework that provides the most holistic view of the
patient’s condition?
a. Head-to-toe pattern
b. Functional Health Patterns
c. Cephalic-caudal pattern
d. Body systems model
b. Functional Health Patterns
Rationale: Marjory Gordon developed the Functional Health Patterns to help nurses focus on patient strengths and related but sometimes overlooked data relationships.
This method of organizing patient data is a more holistic approach than the others because it includes data such as values, beliefs, and roles in addition to physical data.
Organizing assessment data in a head-to-toe (cephalic-caudal) pattern ensures that all areas of concern are addressed as the nurse performs an assessment covering the entire body.
The body systems model organizes data on the basis of each system of the body: integumentary, respiratory, cardiovascular, nervous, reproductive, musculoskeletal, gastrointestinal, genitourinary, and immune systems. It follows a sequence similar to the medical model for physical examination.
The body systems model for data organization tends to focus on the physical aspects of a patient’s condition rather than a more holistic view.
The nurse knows what should be included in an in-depth health history? (Select all that apply.)
a. Demographic data
b. Patient’s allergies
c. Family history of diseases
d. Patient’s health promotion practices
e. Patient’s history of illness and surgery
a. Demographic data
b. Patient’s allergies
c. Family history of diseases
d. Patient’s health promotion practices
e. Patient’s history of illness and surgery
Rationale: An in-depth health history includes all pertinent information that can guide the development of a patient-centered plan of care. The health history includes demographic data, which are collected during the orientation phase of the interview; a patient’s chief
complaint or reason for seeking health care; history of current and past illnesses and surgery; allergies; medications; adverse reactions to medications; medical history; family and social history; and health promotion practices. Because a patient’s health history is continuously evolving, the data collection is ongoing, progressive, and methodical.
The nurse is admitting a patient for uncontrolled diabetes mellitus. The nurse suspects that the patient could benefit from diabetic teaching. What actions by the nurse will assist in validating this suspicion? (Select all that apply.)
a. Determine the patient’s cognitive ability and potential language barriers.
b. Gather information about what the patient already knows about diabetes.
c. Have the patient demonstrate checking a blood glucose level.
d. Formulate the patient’s plan of care using a standard protocol.
e. Prepare to teach the patient using materials written at a third-grade level.
b. Gather information about what the patient already knows about diabetes.
c. Have the patient demonstrate checking a blood glucose level.
Rationale: Data that would validate the nurse’s suspicion that the patient needs further education include determining what the patient already
knows about diabetes and having the patient demonstrate the technique of blood glucose monitoring. If the nurse is correct, further
education is needed. Before further education can occur however; the nurse should determine if the patient has cognitive difficulties or a language barrier which would all contribute to an individualized plan of care. Reading material should typically be written at a
fifth-grade level, but the nurse should not assume the patient needs third-grade level material.
The nurse is preparing to begin a physical examination for a patient with open lesions on the lower extremities. Which would the nurse evaluate during the physical assessment? (Select all that apply.)
a. Blood test results
b. X-ray results
c. Recent vital signs
d. Patient’s health history
e. Subjective data
a. Blood test results
b. X-ray results
c. Recent vital signs
Rationale: On completion of the patient interview, health history, and review of systems, the nurse begins the physical assessment. During the physical assessment, the nurse collects objective data. If diagnostic tests, such as blood tests or x-rays, were ordered before the patient was seen, the results are reviewed by the nurse. Vital signs are taken and recorded at the beginning of the physical
examination.
The charge nurse is planning vital sign assignments for the unlicensed assistive personnel (UAP) on a busy medical-surgical unit. Which patients are appropriate for the UAP to obtain vital signs? (Select all that apply.)
a. A 28-year old patient scheduled to be discharged home today
b. A 49-year-old patient with stable chronic lung disease
c. A 78-year-old patient with recent onset of rectal bleeding
d. A 35-year-old patient waiting for transfer to a rehabilitation center
e. A 40-year-old patient being admitted from the emergency department
a. A 28-year old patient scheduled to be discharged home today
b. A 49-year-old patient with stable chronic lung disease
d. A 35-year-old patient waiting for transfer to a rehabilitation center
Rationale: Routine assessment of vital signs of a patient who is stable may be delegated to licensed practical or licensed vocational nurses (LPNs/LVNs) or qualified UAP. Initial and ongoing assessment of patients requiring critical care or who are unstable cannot be
delegated to UAPs. The patient with rectal bleeding may need critical care, and a new admission needs to be assessed by an RN.
Stable patients such as patients with stable lung disease or awaiting discharge or transfer can be delegated to UAP.
The nurse identifies which examples listed indicate objective data? (Select all that apply.)
a. Respirations—24 breaths/min
b. Platelet count—350,000 mm3
c. Wound size—3 cm × 2 cm
d. Temperature—98.4 °F (36.8 °C)
e. Reports severe abdominal pain
a. Respirations—24 breaths/min
b. Platelet count—350,000 mm3
c. Wound size—3 cm × 2 cm
d. Temperature—98.4 °F (36.8 °C)
Rationale: Objective data, also referred to as signs, can be measured or observed. The nurse’s senses of sight, hearing, touch, and smell are used to collect objective data.
Objective assessment data are acquired through observation, physical examination, and analysis of
laboratory and diagnostic test results. Subjective data are spoken information or symptoms that cannot be authenticated.
Subjective data usually are gathered during the interview process if patients are well enough to describe their symptoms.
Patient-centered care requires the nurse to complete which actions? (Select all that apply.)
a. Have an understanding of patient preferences.
b. Be aware of family values.
c. Recognize the patient’s expectations.
d. Base conclusions on the nurse’s personal experiences.
e. Provide care in a standardized manner.
a. Have an understanding of patient preferences.
b. Be aware of family values.
c. Recognize the patient’s expectations.
Rationale: Patient-centered care requires the nurse to understand patient and family preferences and values. Nurses must recognize patients’ expectations for care and provide care with respect for the diversity of human experience.
While interpreting data, the nurse must be careful to avoid inaccurate inferences (i.e., conclusions) based on the nurse’s personal preferences, past experiences,
generalizations, or outdated and inaccurate health care information.
The nurse completes a health and physical assessment on a patient admitted with a fractured pelvis. Which task would the nurse do next?
a. Analyze and cluster the assessment information.
b. Formulate a Nursing diagnosis addressing actual issues.
c. Determine the need for potential Nursing diagnoses.
d. Create health promotion diagnoses for the patient.
a. Analyze and cluster the assessment information.
Rationale: Nursing diagnosis is the second step of the nursing process. Formulation of nursing diagnoses follows patient data collection and involves the analysis and clustering of related assessment information. Actual nursing diagnoses identify existing problems or
concerns of a patient. Risk nursing diagnoses apply when there is an increased potential or vulnerability for a patient to develop a problem or complication. Health-promotion nursing diagnoses are used in situations in which patients express interest in improving
their health status through a positive change in behavior. The analysis of information is required to determine nursing diagnoses.
