1. The nurse is caring for a group of patients on a medical-surgical unit. Which patient should the licensed practical nurse/licensed vocational nurse (LPN/LVN) assess first?
1.
A patient with a blood glucose of 42 mg/dL
2.
A patient who reports a pain level of 2
3.
A patient who has just received a diagnosis of cancer
4.
A patient who has a respiratory rate of 22
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs.
Pages: 6–7
Heading: Prioritize Care
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE—Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1
This patient has a dangerously low blood glucose level and requires immediate intervention.
2
This patient will need to be assessed, but is not as high a priority.
3
According to Maslow, psychosocial needs are not as high of a priority as physiological needs.
4
A respiratory rate of 22 is within normal range.
PTS: 1 CON: Patient-Centered Care
2. The LPN/LVN enters the room of a patient who is angry and yells, “I asked 5 minutes ago for my pain medication. I’m going to call the CEO of the hospital if you don’t get it for me now.” Which statement by the nurse demonstrates intellectual empathy?
1.
“We are short-staffed today, so it will take me longer to meet your needs.”
2.
“I am sorry you had to wait, I know you must be in a lot of pain.”
3.
“I had another patient who had severe pain, and I had to get to them first.”
4.
“I will get you the number for the CEO, but he is aware of how busy we are.”
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote good critical thinking
Page: 2
Heading: Intellectual Empathy
Integrated Process: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1
This statement does not consider an individual’s situation.
2
This statement demonstrates intellectual empathy by considering this patient’s situation and will likely alleviate the patient’s anger.
3
This statement does not consider a patient’s situation and does not demonstrate intellectual empathy.
4
This statement addresses the patient’s statement of wanting to call the CEO, but does not demonstrate intellectual empathy by considering the patient’s situation.
PTS: 1 CON: Communication
3. The nurse is collecting data on a patient. Which data are described as subjective?
1.
Respiratory rate of 26 per minute
2.
Patient report of shortness of breath
3.
Coarse lung sounds bilaterally
4.
Cough producing green sputum
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 5. Differentiate between objective and subjective data.
Page: 4
Heading: Subjective Data
Integrated Process: Communication and Documentation
Client Need: Communication and Documentation
Cognitive Level: Application (Applying)
Concept: Communication
Difficulty: Moderate
Feedback
1
Respiratory rate of 26 per minute is an example of objective data.
2
A patient reporting symptoms to the nurse is an example of subjective data.
3
Coarse lung sounds is an example of objective data.
4
A productive cough is an example of objective data.
PTS: 1 CON: Communication
4. A patient with a newly fractured femur reports a pain level of 8/10 and analgesic medication is not due for another 50 minutes. Which action should the nurse take first?
1.
Reposition the patient.
2.
Give the medication in 30 minutes.
3.
Notify the registered nurse (RN) or physician.
4.
Tell the patient it is too early for pain medication.
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process.
Page: 3
Heading: Clinical Judgement
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE—Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
The patient who has a fractured femur is having acute pain. Repositioning a patient with a new fracture is not likely to relieve pain.
2
Giving the medication before the prescribed time is beyond the nurse’s scope of practice.
3
The patient should not have to wait for pain relief, so the LPN should inform the RN or physician so new pain relief orders can be obtained.
4
The nurse needs to do more than expect the patient to wait for pain relief.
PTS: 1 CON: Patient-Centered Care
5. The nurse is prioritizing care based on Maslow hierarchy of needs. Which need does the nurse identify as having the highest priority?
1.
Job-related stress
2.
Feeling of loneliness
3.
Pain level of 9 on 0-to-10 scale
4.
Lack of confidence
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs
Page: 7
Heading: Prioritize Care
Integrated Process: Caring
Client Need: SECE – Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
Job-related stress falls under safety according to Maslow and is addressed after physiological needs.
2
According to Maslow, loneliness is addressed under social needs following physiological and safety.
3
Pain is a physiological need and is the highest priority.
4
Lack of confidence falls under esteem according to Maslow and is addressed following physiological, safety, and social needs.
PTS: 1 CON: Patient-Centered Care
6. The nurse is planning care and setting goals for a newly admitted patient. Who should the nurse include when conducting these nursing actions?
1.
Patient
2.
Nurse manager
3.
Hospital chaplain
4.
Patient’s health care provider (HCP)
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse is using the nursing process.
Page: 6
Heading: Prioritize Care
Integrated Process: Communication and Documentation
Client Need: SECE—Management of Care
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1
Planning care and setting goals is an action performed with the patient. The patient must be in agreement with the plan for it to be successful in meeting the desired outcomes.
2
The nurse manager may or may not be aware of the patient’s care needs.
3
The hospital chaplain may not be aware of the patient’s needs.
4
The focus of nursing care is different from that of the HCP.
PTS: 1 CON: Communication
7. While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes serosanguineous drainage on the dressing. Which statement should the nurse use to document this finding?
1.
“Normal drainage noted.”
2.
“Moderate drainage recently noted.”
3.
“Scant serosanguineous drainage seen on dressing.”
4.
“Pale pink drainage 2 cm by 1 cm noted on dressing.”
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 6. Document subjective and objective data.
Page: 5
Heading: Documentation of Data
Integrated Process: Communication and Documentation
Client Need: PHYS—Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Communication
Difficulty: Moderate
Feedback
1
These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting.
2
These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting.
3
These statements are interpretations of the data and use words that have vague meanings, which should be avoided when documenting.
4
Objective data are pieces of factual information obtained through physical assessment and diagnostic tests that are observable or knowable through the five senses. The nurse should document exactly what is seen.
PTS: 1 CON: Communication
8. The nurse is caring for a patient using the nursing process. Which step should the nurse take first?
1.
Implementation
2.
Planning
3.
Nursing diagnosis
4.
Assessment
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process.
Page: 4
Heading: Data Collection
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
The steps of the nursing process are data collection/assessment, nursing diagnosis, planning, implementation, and evaluation.
2
The steps of the nursing process are data collection/assessment, nursing diagnosis, planning, implementation, and evaluation.
3
The steps of the nursing process are data collection/assessment, nursing diagnosis, planning, implementation, and evaluation.
4
Assessment, or data collection, is the first step in the nursing process and is used to evaluate a patient’s condition before providing care. The other steps, in order, are nursing diagnosis, planning, implementation, and evaluation.
PTS: 1 CON: Patient-Centered Care
9. The nurse is administering morphine to a patient reporting a pain level of 8 on a 0-to-10 scale. This describes which step of the nursing process?
1.
Assessment
2.
Nursing diagnosis
3.
Implementation
4.
Evaluation
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process.
Page: 8
Heading: Identify Interventions
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE – Coordination of Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
Administering medication does not describe assessment.
2
Administering medication does not describe nursing diagnosis.
3
Administering medication describes the implementation process, since an action is being taken to help the patient meet a desired outcome.
4
Administering medication does not describe the evaluation phase of the nursing process.
PTS: 1 CON: Patient-Centered Care
10. The nurse is developing an outcome for a patient with exacerbation of asthma. Which is the most appropriate outcome for this patient?
1.
The patient will not experience shortness of breath.
2.
The patient will have a respiratory rate of 16 to 20 per minute.
3.
The patient will ambulate without reporting shortness of breath.
4.
The patient will not require use of an inhaler.
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 8
Heading: Establish Outcomes
Integrated Process: Clinical Problem-solving (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
This is a vague outcome and is not measurable.
2
This is a measurable outcome and is not vague.
3
This is a vague outcome and is not measurable.
4
This is a vague outcome and is not measurable.
PTS: 1 CON: Patient-Centered Care
11. The nurse suspects a patient is experiencing adverse effects to a newly prescribed antihypertensive medication. After being informed that the effects are expected, the nurse remains concerned and conducts an Internet search on the patient’s manifestations. Which critical thinking behavior did the nurse implement?
1.
Sense of justice
2.
Intellectual courage
3.
Intellectual empathy
4.
Intellectual perseverance
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote critical thinking.
Page: 2
Heading: Intellectual Perseverance
Integrated Process: Caring
Client Need: Psychosocial Integrity
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
A sense of justice examines motives when making decisions.
2
Intellectual courage looks at other points of view, even when the nurse does not agree with them.
3
Intellectual empathy understands how another person feels when making decisions.
4
Intellectual perseverance is not giving up.
PTS: 1 CON: Patient-Centered Care
12. The nurse is identifying outcomes for a patient with fluid volume deficit. Which outcome should the nurse use to guide this patient’s care?
1.
Patient’s intake will be measured daily.
2.
Patient’s intake will be 3,000 mL daily.
3.
Fluids will be at the bedside for the patient.
4.
Fluids the patient likes will be at the bedside.
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 7
Heading: Establish Outcomes
Integrated Process: Clinical Problem-solving (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
These statements are nursing actions.
2
This outcome provides objective measurable data.
3
These statements are nursing actions.
4
These statements are nursing actions.
PTS: 1 CON: Patient-Centered Care
13. The nurse is formulating nursing diagnoses for a patient with chronic obstructive pulmonary disease (COPD). Which diagnosis is of the highest priority?
1.
Activity intolerance
2.
Impaired gas exchange
3.
Risk for injury
4.
Deficient knowledge
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs.
Page: 6
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1
Although activity intolerance is a nursing diagnosis for a patient with COPD, it is not the highest priority.
2
Impaired gas exchange is the highest priority according to Maslow.
3
A risk for diagnosis is not a priority because the patient is only at risk for the problem, it is not an actual problem as of yet.
4
According to Maslow, deficient knowledge is not a priority.
PTS: 1 CON: Patient-Centered Care
14. An RN delegates a patient care assignment to the LPN/LVN. Which phase of the nursing process should the LPN/LVN perform independently?
1.
Assessment
2.
Planning care
3.
Implementation
4.
Nursing diagnosis
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process.
Page: 22
Heading: Role of the Licensed Practical Nurse/Licensed Vocational Nurse
Integrated Process: Clinical Problem-Solving (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
The LPN/LVN assists the RN with collecting data, formulating nursing diagnoses, and in determining outcomes and planning care to meet patient needs.
2
The LPN/LVN assists the RN with collecting data, formulating nursing diagnoses, and in determining outcomes and planning care to meet patient needs.
3
The LPN/LVN independently provides direct patient care.
4
The LPN/LVN assists the RN with collecting data, formulating nursing diagnoses, and in determining outcomes and planning care to meet patient needs.
PTS: 1 CON: Patient-Centered Care
15. The LPN/LVN is reviewing a care plan for a patient who underwent abdominal surgery 2 hours ago and has a priority nursing diagnosis of acute pain. Which intervention should the nurse implement first?
1.
Teach the patient how to splint the abdomen when coughing.
2.
Assist the patient with early ambulation.
3.
Encourage the patient to increase fluid intake.
4.
Administer hydromorphone (Dilaudid) per order as needed for pain.
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs.
Page: 6
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1
Splinting is important, but if the patient is in pain, he or she will not likely retain information.
2
Early ambulation is important, but does not address the diagnosis of acute pain.
3
The patient may need to increase fluid intake, but this is not a priority intervention.
4
The patient has a nursing diagnosis of acute pain; this intervention should be implemented first.
PTS: 1 CON: Patient-Centered Care
16. Which critical thinking trait is demonstrated when the LPN/LVN is unsure of how to perform a dressing change and asks the RN for assistance?
1.
Intellectual courage
2.
Intellectual integrity
3.
Intellectual humility
4.
Intellectual empathy
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 2. Describe attitudes and skills that promote good critical thinking.
Page: 2
Heading: Intellectual Humility
Integrated Process: Communication and Documentation
Client Need: Psychosocial Integrity
Cognitive Level: Comprehension (Understanding)
Concept: Communication
Difficulty: Moderate
Feedback
1
Intellectual courage allows the nurse to look at other points of view even if he or she does not agree.
2
Intellectual integrity is holding oneself to the same level of standards one expects others to meet.
3
The LPN/LVN is demonstrating intellectual humility, which is having the ability to ask for assistance when he or she is unsure.
4
Intellectual empathy allows the nurse to put himself or herself in the patient’s shoes.
PTS: 1 CON: Communication
17. During morning report, the LPN/LPN is assigned a group of patients. Which patient should the LPN/LPN see first?
1.
A patient scheduled for magnetic resonance imaging (MRI) due to back pain
2.
A patient reporting constipation and stomach cramps
3.
A 2-day postsurgical patient reporting pain at a level of 6
4.
A patient with pneumonia who is short of breath and anxious
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs.
Page: 3
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1
The patient’s problems of pain, constipation, and scheduled tests are all important but are not immediately life threatening.
2
The patient’s problems of pain, constipation, and scheduled tests are all important but are not immediately life threatening.
3
The patient’s problems of pain, constipation, and scheduled tests are all important but are not immediately life threatening.
4
Using Maslow hierarchy of needs and considering which patient problems are life threatening, shortness of breath is most important.
PTS: 1 CON: Patient-Centered Care
18. The LPN/LVN asks a patient who received 2 mg of Morphine IV 30 minutes ago to rate his or her pain. This describes which step of the nursing process?
1.
Assessment
2.
Planning
3.
Implementation
4.
Evaluation
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 8
Heading: Evaluation of Outcomes
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
The assessment process would be conducted prior to administering the Morphine.
2
This does not describe the planning phase of the nursing process.
3
The implementation phase of the nursing process is the administration of Morphine.
4
Asking the patient if the Morphine was effective by asking him or her to rate the pain describes the evaluation phase of the nursing process.
PTS: 1 CON: Patient-Centered Care
19. The LPN/LVN is assisting the RN in planning interventions for a patient. Which is an example of a collaborative action?
1.
Administering a medication
2.
Giving a back rub
3.
Assessing a patient
4.
Teaching relaxation techniques
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 6
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
Administering a medication requires an order from the HCP, which makes this a collaborative action.
2
Giving a back rub is an independent nursing action.
3
Assessing a patient is an example of an independent nursing action.
4
Teaching relaxation techniques is an example of an independent nursing action.
PTS: 1 CON: Patient-Centered Care
20. The LPN/LVN is reviewing nursing diagnoses for a patient. Which diagnosis should the nurse report to the RN as incorrect?
1.
Risk for injury
2.
Heart failure
3.
Ineffective gas exchange
4.
Activity intolerance
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 4. Identify the role of a licensed practical nurse/licensed vocational nurse in using the nursing process.
Page: 6
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
Risk for injury is a nursing diagnosis and does not require correction.
2
Heart failure is a medical diagnosis and requires correction.
3
Ineffective gas exchange is a nursing diagnosis and does not require correction.
4
Activity intolerance is a nursing diagnosis and does not require correction.
PTS: 1 CON: Patient-Centered Care
21. The LPN/LVN is caring for a group of patients. Which patient should the nurse assess first?
1.
A patient with an oxygen saturation level of 96% on room air
2.
A patient who has a blood pressure of 208/114 mm Hg
3.
A patient who reports a pain level of 7 on a scale of 0 to 10
4.
A patient with a temperature of 100.2°F
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs.
Page: 7
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1
An oxygen saturation of 96% is not too concerning. This is not the highest priority.
2
A blood pressure of 208/114 mm Hg is very high and should be addressed immediately. This patient should be seen first.
3
This patient is in pain and should be seen, but is not as high of a priority as the patient with hypertension.
4
This patient has a low-grade temperature, which is not a priority.
PTS: 1 CON: Patient-Centered Care
22. The LPN/LVN is caring for a patient who begins to exhibit shortness of breath and chest pain. Which action should the nurse take first?
1.
Administer medication as ordered.
2.
Notify the RN.
3.
Document the findings in the chart.
4.
Reposition the patient.
ANS: 2
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs.
Page: 3
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1
The nurse will likely need to administer medication, but should first notify the RN of the patient’s condition.
2
The LPN/LVN should notify the RN immediately of the change in the patient’s status.
3
The nurse will document the findings in the chart, but should first notify the RN.
4
Repositioning the patient may not help in this situation; the LPN/LVN should first notify the RN.
PTS: 1 CON: Patient-Centered Care
23. While teaching how to apply a topical medication the patient begins to vomit. Which action should the nurse take to meet the patient’s human needs?
1.
Provide a clean gown before resuming the teaching.
2.
Position an emesis basin for patient use while teaching.
3.
Administer medication prescribed for nausea and vomiting.
4.
Wait for the vomiting to stop and begin the teaching session again.
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs.
Page: 7
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
These actions do not take the patient’s physiological needs into consideration. The patient will not be able to achieve a higher level of the hierarchy before basic physiological needs are met.
2
These actions do not take the patient’s physiological needs into consideration. The patient will not be able to achieve a higher level of the hierarchy before basic physiological needs are met.
3
Basic physiological needs must be met first. Since the patient is vomiting, the nurse should provide the medication that is prescribed for nausea and vomiting.
4
These actions do not take the patient’s physiological needs into consideration. The patient will not be able to achieve a higher level of the hierarchy before basic physiological needs are met.
PTS: 1 CON: Patient-Centered Care
24. A nurse approaches a person in a restaurant who appears to be experiencing respiratory distress. Which action should the nurse perform first?
1.
Diagnose the problem.
2.
Assist the person to lie down.
3.
Gather data from other people.
4.
Collect data about the person’s condition.
ANS: 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 7
Heading: Subjective Data
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application (Applying)
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
Diagnosing the problem would occur after collecting data.
2
Assisting the person to lie down is implementing an action to address the problem.
3
The nurse can collect data from other people if necessary.
4
The first step in the nursing process is to collect data, and the patient should come first.
PTS: 1 CON: Patient-Centered Care
25. The nurse is reviewing nursing diagnoses. Which is an example of a correctly written nursing diagnosis?
1.
Acute pain related to tissue trauma as evidenced by facial grimacing and rating pain at a level of 9 on a 0-to-10 scale
2.
Pain related to appendicitis as evidenced by moaning and guarding
3.
Acute pain related to guarding abdomen and rating pain at a level of 9 on a 0-to-10 scale
4.
Pain as evidenced by status postsurgical procedure
ANS: 1
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 6
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
This is a well-written three-part nursing diagnosis that includes the etiology and signs and symptoms.
2
This is a medical diagnosis, not a nursing diagnosis.
3
This nursing diagnosis is missing correct etiology.
4
This is a medical diagnosis and is also missing correct signs and symptoms.
PTS: 1 CON: Patient-Centered Care
26. After identifying nursing diagnoses the nurse plans outcomes for a patient with gastroesophageal reflux disease. Which outcome should the nurse use to evaluate this patient’s care?
1.
The patient will have less heartburn.
2.
The patient will sleep through the night.
3.
The patient’s esophageal burning will resolve 30 minutes after taking oral antacids.
4.
The patient will state that burning only occurs when eating foods high in acid content.
ANS: 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 8
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1
Outcomes should not be vague or open to interpretation, and should use subjective words such as normal, large, small, or moderate.
2
Sleeping through the night may or may not be associated with the patient’s problem.
3
Outcomes should be measurable, realistic for the patient, and have an appropriate time frame for achievement.
4
Stating that the burning only occurs with eating foods high in acid content is a patient statement that could be used for subjective data collection.
PTS: 1 CON: Patient-Centered Care
MULTIPLE RESPONSE
1. After collecting data, the nurse identifies diagnoses to guide the patient’s care. Which diagnoses did the nurse document correctly? (Select all that apply.)
1.
Diabetes
2.
Acute pain
3.
Pancreatitis
4.
Activity intolerance
5.
Impaired physical mobility
ANS: 2, 4, 5
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 8
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1.
Diabetes and pancreatitis are medical diagnoses.
2.
Acute pain, activity intolerance, and impaired physical mobility are nursing diagnoses.
3.
Diabetes and pancreatitis are medical diagnoses.
4.
Acute pain, activity intolerance, and impaired physical mobility are nursing diagnoses.
5.
Acute pain, activity intolerance, and impaired physical mobility are nursing diagnoses.
PTS: 1 CON: Patient-Centered Care
2. A patient with a family history of diabetes is experiencing high blood glucose levels, confusion, an unsteady gait, and dehydration. Which nursing diagnoses should the nurse identify as appropriate for this patient’s care? (Select all that apply.)
1.
Diabetes
2.
Dehydration
3.
Risk for falls
4.
Hyperglycemia
5.
Deficient fluid volume
ANS: 3, 5
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 6
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1.
Diabetes, dehydration, and hyperglycemia are medical problems. The nurse assists with medical diagnoses; however, the nurse does not diagnose and treat medical problems.
2.
Diabetes, dehydration, and hyperglycemia are medical problems. The nurse assists with medical diagnoses; however, the nurse does not diagnose and treat medical problems.
3.
Deficient fluid volume and risk for falls are nursing diagnoses related to the patient’s symptoms and condition.
4.
Diabetes, dehydration, and hyperglycemia are medical problems. The nurse assists with medical diagnoses; however, the nurse does not diagnose and treat medical problems.
5.
Deficient fluid volume and risk for falls are nursing diagnoses related to the patient’s symptoms and condition.
PTS: 1 CON: Patient-Centered Care
3. The nurse identifies the diagnosis potential for ineffective gas exchange as appropriate for a patient with pneumonia. Which independent nursing actions should the nurse plan for this problem? (Select all that apply.)
1.
Apply oxygen 2 liters per nasal cannula.
2.
Turn and reposition in bed every 2 hours.
3.
Coach to deep-breathe and cough every hour.
4.
Administer intramuscular antibiotic medication.
5.
Encourage to drink 240 mL of fluid every 2 hours.
ANS: 2, 3, 5
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 6
Heading: Nursing Diagnosis
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1.
Interventions that need an HCP’s order include administering oxygen and medication. These are collaborative interventions.
2.
Independent nursing actions are those that can be implemented without an HCP’s order.
3.
Independent nursing actions are those that can be implemented without an HCP’s order.
4.
Interventions that need an HCP’s order include administering oxygen and medication. These are collaborative interventions.
5.
Independent nursing actions are those that can be implemented without an HCP’s order.
PTS: 1 CON: Patient-Centered Care
4. The nurse is planning outcomes for a patient with acute pain who is exhibiting tachypnea and hypertension. Which outcomes should be included in the patient’s care?
1.
Patient will rate pain at a level of 2 on a 0-to-10 scale 30 minutes after receiving Morphine.
2.
Patient will ambulate without pain.
3.
Patient will not exhibit signs or symptoms of pain.
4.
Patient will maintain respiratory rate between 16 and 20.
5.
Patient’s blood pressure will remain within normal limits.
ANS: 1, 4
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 6
Heading: Establish Outcomes
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Application [Applying]
Concept: Patient-Centered Care
Difficulty: Moderate
Feedback
1.
This is a measurable and specific outcome.
2.
This is not a measurable outcome and is too vague.
3.
This is not a measurable outcome and is vague.
4.
This is a measurable and specific outcome.
5.
This outcome is not specific and is not measurable. The nurse should define normal limits.
PTS: 1 CON: Patient-Centered Care
ORDERED RESPONSE
1. The nurse is caring for a group of patients. Place in order the patients the nurse should see from highest to lowest priority (1 to 5).
1. A patient who underwent abdominal surgery yesterday and reports a pain level of 5 on a 0-to-10 scale
2. A patient with deep vein thrombosis (DVT) who reports shortness of breath
3. A patient awaiting education from the diabetes educator
4. A patient with eczema who reports itching
5. A patient who reports nausea after chemotherapy
ANS:
2, 1, 5, 4, 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 7. Prioritize patient care activities based on the Maslow hierarchy of human needs.
Page: 6
Heading: Prioritize Care
Integrated Process: Clinical Problem-solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Analysis (Analyzing)
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1.
The patient in pain is a priority, but should be seen after the patient with shortness of breath.
2.
The patient with DVT exhibiting shortness of breath could have a pulmonary embolism and should be seen first.
3.
A patient waiting for diabetes education is not a priority and can be seen last in this group of patients.
4.
Itching is a symptom of eczema and is a priority, but not as high a priority as shortness of breath, pain, or nausea. This patient can be seen fourth.
5.
Nausea is a priority, but this patient can be seen after the patient with shortness of breath and pain.
PTS: 1 CON: Patient-Centered Care
2. The nurse is caring for a patient recovering from a stroke. Place in the order of the nursing process the observations or actions provided while caring for this patient.
1. Hand grasp absent left hand
2. Alteration in cerebral perfusion
3. Flexed left thumb and index finger
4. Coached to squeeze rubber ball placed in left hand
5. Self-feed using left hand
ANS:
1, 2, 5, 4, 3
Chapter: Chapter 1 Critical Thinking and the Nursing Process
Objective: 3. Describe the thinking that occurs in each step of the nursing process.
Page: 4
Heading: NURSING PROCESS
Integrated Process: Clinical Problem-Solving Process (Nursing Process)
Client Need: SECE: Coordinated Care
Cognitive Level: Analysis [Analyzing]
Concept: Patient-Centered Care
Difficulty: Difficult
Feedback
1.
Assessed data is the absence of a left-hand grasp.
2.
The nursing diagnosis that is associated with the absence of a hand grasp is alteration in cerebral perfusion.
3.
The patient flexing the left thumb and index finger evaluates the success of the intervention of squeezing a rubber ball in the left hand.
4.
Coaching to squeeze a rubber ball in the left hand is an intervention to improve left hand function.
5.
The goal of nursing care is for the patient to self-feed using the left hand.
PTS: 1 CON: Patient-Centered Care
