What is pivotal to determining how do you move from each patient problem to its goals quizlet?
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Which foundational behavior is necessary for effective critical thinking? Show
A. Unshakeable beliefs and values An open-minded attitude The nurse is assessing a new patient who complains of his chest feeling tight. The patient displays a temperature of 100F and an oxygen saturation of 89% and exportorates frothy mucus. Which finding is an example of subjective data? A. Temperature Chest tightnes The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse. This scenario is an example of which type of source? A. Primary Primary The nurse is performing an intake interview on a new resident to the long-term care facility. The nurse detects the odor of acetone from the patient's breath. Which term accurately describes this assessment? A. Inspection Olfaction
During a morning assessment, the nurse observes that the patient displays significant edema of both feet and ankles. Which statement best documents these findings? A. Pitting edema present in both feet and ankles Bilateral pitting edema in feet and ankles, 4 mm deep, resolving in 3 seconds Which technique should the nurse employ to best assess skin turgor? A. Examine mucous membranes of the mouth Pinch a skinfold on chest to assess for tenting Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA)? A. The student uses the patient's full name only on clinical assignments submitted to the instructor The student shreds any documents that contain identifying patient information before leaving the clinical facility The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility. Which goal/outcome statement best correlates with this diagnosis? A. The patient will sit in a
chair at bedside for 15 minutes after each meal The patient will sit in chair at bedside for 15 minutes after each meal The nurse who has recently moved from Lousiana to Texas is uncertain about the LPN/LVN's role in applying the nursing process. Which source is the most appropritate source for the nurse to consult? A. Hospital policies The Texas State Board of Nursing The nurse adds a nursing order to the care plan related to a patient with a problem statement/nursing diagnosis of altered nutrition/Nutrition: Less Than Body Requirements Related to Nausea and Vomiting. Which nursing order should the nurse include in the plan of care? A. Medicate with an antiemetic before each meal Offer crackers and iced drink before each meal
After evaluating the nursing care plan, the nurse finds lack of progress toward the goal. What action should the nurse take? A. Create a more accessible goal Revise the nursing interventions During an intake interview, the nurse observes the patient grimacing and holding his hand over his stomach. The patient previously denied having any pain. What action should the nurse take next? A. Examine the history closely for etiology of pain Ask the patient if he is experiencing abdominal pain While conducting an admission interview, the nurse questions the patient about pain. The patient responds, "No. I'm pretty wobbly." Which action should the nurse take next? A. Repeat the question about pain Ask the patient to clarify his meaning The nurse is caring for a patient with a goal/outcome statement of Patient will sleep for 5 h uninterrupted each night. Which nursing intervention should the nurse include? A. Medicate with sedative each night Discourage daytime napping The nursing team is prioritizing the problem statement/nursing diagnoses of an overnight hospital patient. Which problem statement/nursing diagnosis would be most important for this patient? A. Risk for dehydration related to vomiting Activity intolerance related to shortness of breath The nurse is explaining the components of a complete problem statement/nursing diagnosis. In addition to the NANDA stem and etiology, which other component should the diagnosis include? A. A time reference for meeting the need Signs and symptoms of the problem assessed Which statement explains the reason for the inclusion of potential problems in the nursing care plan? A. To alert nursing staff to prevent potential complication To alert nursing staff to prevent potential complication The nurse is completing the medication reconciliation form for a patient. Which information is most important for the nurse to include? A. The patient reports taking Ginkgo biloba daily for the last 6 months The patient reports taking Ginkgo biloba daily for the last 6 months The nurse is caring for a patient with pneumonia who complains of shortness of breath. Further assessment reveals an oxygen saturation of 89% on room air, 28 respirations/min with bilateral crackles in lung bases, blood pressure of 160/94, and a pulse rate of 102 beats per minute. Which nursing diagnosis is priority for this patient? A. Activity intolerance Impaired gas exchange The nursing student demonstrates knowledge of the proper use of the following when determining that it is safe to administer meperidine (Demerol) and promethazine (Phenergan) together? A. Medication reconciliation form Medication reconciliation form The nurse explains to the nursing student that the application of critical thinking to patient care involves which factor(s)? (Select all that apply) A. Identification of a patient problem 1. Identification of a patient problem Which statement(s) demonstrates the application of the nursing process? (select all that apply) A. Performing a head-to-toe assessment 1. Performing a head-to-toe assessment Characteristics of an interdisciplinary care plan include which of the following? (select all that apply) A. Patient problem focuses 1. Patient problem focuses Place the steps of the nursing process in their proper sequence. A. Evaluation 1. Assessment Which critical thinking skill is important to apply when formulating a nursing care plan? A. Having the nursing assistant help with assessment Analyzing the data to determine appropriate nursing diagnoses *Analyzing the data from all areas of the assessment is use of critical thinking. (1) Using the nursing assistant is part of delegation. (2) Reading the history and physical in the chart is appropriate but not a use of critical thinking. (4) Including the patient in care planning is appropriate but not a use of critical thinking. Critical thinking is important in the nursing process because it A. Can provide a better outcome for the patient Can provide a better outcome for the patient *Critical thinking can help create a better care plan and provide a better outcome for the patient. (2) It does not simplify the planning process for the nurse. (3) The patient should have input on the plan with or without the use of critical thinking. (4) Writing out the plan communicates it to others, not critical thinking. The assessment technique of percussion is used by the nurse to A. Determine whether lung sounds are normal Assess for air in the intestine *Percussion assists in determining if there is air in the intestine. (1) Auscultation is used to determine if lung sounds are normal. (3) Palpation is used to determine abdominal rigidity. (4) The patient must verbalize the degree or amount of abdominal pain. Assessing a patient's sleep patterns should include which aspect(s)? (Select all that apply) A. Family history of sleep disorders 1. Rituals associated with sleep *Rituals can be very comforting when trying to sleep. Feelings of restfulness help the individual go to sleep. Dietary sources (e.g., foods that cause indigestion, gas, and diarrhea) can keep the person awake. Urinary difficulties such as frequency or urgency can disturb sleep. (1) Family history of sleep disorders is only pertinent if the patient has always suffered from insomnia. When caring for an older woman who developed a 5-cm pressure ulcer on her sacrum because of being immobilized and incontinent, an appropriate expected outcome for the problem of altered skin integrity would be A. "Patient will be able
to ambulate to the bathroom with minimal assistance." "Patient will demonstrate a decrease in size of the ulcer within 1 week." *Patient will demonstrate a decrease in size of the ulcer within 1 week is an appropriate expected outcome. (1) The ability to ambulate to the bathroom will help prevent further ulceration but will not directly decrease the impaired skin integrity. (2) A turning and repositioning schedule for the staff should be on the chart, but it is not an appropriate expected outcome. (4) It is desirable for the family to bring in protein-rich food for the patient to help the ulcer heal, but that is not an expected outcome. Risk for falls would be considered a high priority for a patient with which of these problems? (select all that apply) A. Altered skin due to repair of umbilical hernia. 1. Altered mobility due to knee
arthritis. *Altered mobility due to knee arthritis puts the patient at an increased risk for falls, making the assessment a high priority. Decreased cardiac output also could contribute to fall risk. (1) Altered skin integrity does not increase the risk for falls. (3) Altered nutrition and excessive weight do not in themselves create a risk for falls. (4) An alteration in self-care ability does not create a risk for falls, although extreme weakness in an ambulatory patient would create a greater risk for falls. (5) Altered swallowing does not increase fall risk. The nurse is collecting data from an older patient with a history of fractures who has just had gallbladder surgery. Along with a focused assessment, the nurse should include: A. determining orientation to person, place, and time. determining orientation to person, place, and time. *Determining orientation to person, place, and time in order to plan safe care for the patient is important since surgery in an older adult may cause electrolyte shifts that lead to more confusion and disorientation, which could cause a fall and another fracture. (2) Auscultating for a heart murmur is not pertinent to postoperative care by the LPN/LVN, as a health care provider would detect this before surgery. (3) Checking peripheral pulses is standard to the care of a postoperative patient and not pertinent to the potential risk for fracture in this patient at this time. (4) Testing active and passive range of motion is not pertinent to postoperative care after gallbladder surgery. When evaluating patient understanding regarding the use of an incentive spirometer, which statement confirms a need for more teaching? A. "I will inhale as deeply as possible each time I use the spirometer." "I need to tilt the incentive spirometer slightly to reduce effort." *Tilting the incentive spirometer is not a correct use of the device and indicates a need for further teaching. (1) Inhaling deeply with each use of the spirometer is correct. (3) Recording the top volume achieved helps record progress in lung reexpansion. (4) Sealing the lips around the mouthpiece is correct technique for the spirometer. Using critical thinking, choose the nursing actions that should be implemented when addressing the needs of an older patient with the problem diagnosis of "Altered nutrition due to poor dentition." (select all that apply) A. Encourage more fluid intake of fluids with food value if not contraindicated by the medication condition 1. Encourage more fluid intake of fluids with food value if not
contraindicated by the medication condition *Small amounts of fluid with food value given frequently are important, unless contraindicated due to a medical condition. The dental condition is already identified, so it is important to monitor the condition of the membranes, teeth, etc. Tracking caloric intake and weekly weights assists in knowing if the patient is progressing. (3) The patient does not need assistance with swallowing. (4) A speech therapist is not warranted for dentition problems. (6) Frequent mouth care will not improve the nutritional status and will not reverse the damage already done to gums and teeth. When evaluating for side effects of the action of "administer anticoagulant," which patient statement(s) would strongly correlate with a side effect problem? (select all that apply) A.
"I have noticed some blood streaking in my bowel movements." 1. "I have noticed some blood streaking in my bowel movements." *Blood streaks in bowel movements can be a side effect of anticoagulant therapy. Bruising is another side effect of anticoagulant therapy. Painful and bloody flossing of teeth can be a side effect of anticoagulant therapy. (2) Gassiness is not a usual side effect of anticoagulant therapy. (3) Cloudy urine and clots can be another side effect of anticoagulant therapy, but cloudy urine and an odd odor more likely indicate a urinary tract infection. When approaching a clinical problem, an important characteristic of a critical thinker is to A. rely on one's own family values in considering a problem Recognize one's own biases and limitations To consider a problem using the nursing process, the nurse must (list in order of priority) A. Consider all possible alternatives as solutions to the problems 1. Define the problem clearly The LPN/LVN contributes to the nursing care plan by A.
devising the problem statements/nursing diagnoses D?????Collaborating with the patient concerning the problems B or D not sure which one is correct The focus of the planning step of the nursing process is A.
implementing nursing interventions determining goals and identifying expected outcomes The most important part of writing expected outcomes for problem statements/nursing diagnoses is to A. State the outcome so that it is
measurable State the outcome so that it is measurable The nurse uses which technique to correctly palpate the abdomen? A. Depresses gently with the fingertips and thumb Gently feels with the flat palmar surface of the fingers The nurse is looking at the patient's chart and other documentation to determine when the patient received the last dose of blood pressure medication. Where would be the best place to locate this information? A. Physician's orders Medication administration record An increased number of white blood cells (WBCs) is most likely to be associate with A. dehydration infection The nurse knows that current signs are important indicators of what is happening at a given moment. In addition, vital signs should be correlated with which patient data? A. Trends of past readings Trends of past readings In the collaboration role of the LPN/LVN and RN, when developing a prioritized list of prblem statements/nursing diagnoses, the two nurses use ______________________ to determine relationships among the data. critical thinking The nurse working on the renal unit is preparing to make the first rounds of the day. Which patient should the nurse visit first? A. The patient with an acute kidney infection. The patient who is 1-h post-kidney transplant. *The patient who is 1-h post-kidney transplant is the least stable patient and should be assessed first. The patient with an acute kidney infection, the patient maintained on hemodialysis, and the patient scheduled for a diagnostic study are lower acuity patients and can be seen after the transplant patient. The nurse has been assigned four patients. Which patient should the nurse visit first? A. The patient with chronic poor circulation to the extremities The patient with chest pain and a history of angina *The patient with chest pain and a history of angina needs further evaluation now. The patient with insulin-dependent diabetes has a normal blood glucose level and does not need to be seen first. The patient with hypertension being maintained on oral medication is stable because of his medication regimen. The patient with chronic poor circulation to the extremities is in no distress. The LPN/LVN is assisting the RN in planning care for a patient. Which should receive the highest priority? A. Mobility Oxygenation *Oxygenation status should be given priority. Although the patient's comfort, mobility, and skin status are important, they are a lower priority than oxygenation status. The student nurse is studying the nursing process. Which statement best describes the nursing process? A. A plan to describe nursing
functions A goal-directed, orderly series of activities *The nursing process is a series of steps planned and followed in an attempt to achieve a patient goal. It is not a plan to describe nursing functions, an attempt to define nursing practice, or a theory of operative nursing standards. When discussing the nursing process, the student nurse correctly states, "The nursing process is designed to provide a means for measuring __________." A. acuity of the patients on a nursing unit patient outcomes *The nursing process allows for measurement of patient outcomes by evaluating whether established patient goals have been met. The nursing process is not used to measure expenses associated with care, appropriate tasks for delegation, or acuity of patients on a nursing unit. In a hospital, a patient who is having trouble breathing is very upset because the LPN/LVN has to help the patient bathe. The patient says to the nurse, "I don't think you should have to bathe me." The nurse's response is based on which of these understandings about the nurse's role? A.
Patients must be encouraged to meet their own needs at all times. Meeting one's basic needs may require assistance from someone until the individual is able to manage independently. *The goal of care is to work toward the patient functioning as independently as possible. The LVN/LPN should distinguish which activities to carry out, and which activities the patient must learn to do to gain independence. The nurse should explain that assistance is given in an attempt to help the patient achieve independence. It is inappropriate to care for patients' needs regardless of their ability to care for themselves. It is also inappropriate to withhold assistance simply because the patient is uncomfortable with receiving it. A patient with a life-threatening condition is brought to the emergency department. The LPN/LVN is to care for the patient. What is the LPN/LVN's first action? A. Determine nursing diagnoses and set priorities for expected goals. Collect data on the patient and recognize priorities. *Following the steps of the nursing process is necessary in order to plan and implement effective patient care. Data collection, planning and implementation of nursing interventions, and evaluation of patient goals are the steps followed. Assessing the major problems and beginning interventions is the role of the provider. Determining nursing diagnoses and setting priorities for expected goals is not the initial action. Complete assessment of the patient and determination of realistic outcomes is not an appropriate first action while the patient is in a life-threatening condition. The LPN/LVN is to interview a newly admitted patient. What is the most important reason that the nurse should review the patient's records before beginning the interview? A. To check the accuracy of those records To enhance observation skills during the nurse's initial patient contact *Reading the current information before entering the patient's room and knowing current information enhances critical thinking and observation skills. The nurse can also check the accuracy of those records and learn as much about the disease process as possible, but these are not the most important reasons. Determining other people's opinions of the patient's problems is not a necessary aspect of the assessment. A nurse has taken several steps to improve his critical thinking skills. Which actions indicate that the nurse is beginning to achieve excellence in critical thinking? (Select all that apply.) A. Self-correcting 1. Self-correcting Which data are considered objective? (Select all that apply.) A. Apical pulse 1. Apical pulse How do you determine whether the patient has reached the goals?You use evaluative measures to determine whether patients have met their goals and outcomes. Evaluative measures are not multiple-page documents, and they are used to assess the patient's status, not the nurse's performance.
What is the clinical reasoning cycle used for?The Clinical Reasoning Cycle requires health care professional to examine and discuss the steps in a clockwise direction to facilitate decision-making, enabling the clear formulation of a care plan (Levett-Jones, et al., 2010). This cycle has been applied in the current scenario involving patient Russell Stanton.
What are steps in clinical reasoning quizlet?Terms in this set (9). What are the 8 steps of the Clinical Reasoning Cycle. Consider the patients situation. ... . Consider the patients situation. Describe/list facts, context, object or people.. Collect cues/information. ... . Process information. ... . Identify problems/issues. ... . Establish goal/s. ... . Take action. ... . Evaluate outcomes.. Can assist the nurse in determining when and when not to use each nursing diagnosis category it assists in ruling out invalid diagnoses and selecting valid diagnoses?Reference texts such as NANDA Nursing Diagnoses: Definitions and Classifications can assist the nurse to determine when and when not to use each nursing diagnostic category. It assists with ruling out invalid diagnoses and selecting valid diagnoses.
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