Exam 1 Practice - Fundamentals of Nursing Part 1

1. Read the following patient scenario and identify the step of the nursing process represented by each numbered and boldfaced nursing activity. Annie seeks the help of the nurse in the student health clinic because she suspects that her roommate, Angela, suffered date rape. She is concerned because Angela chose not to report the rape and does not seem to be coping well. (1) After talking with Annie, the nurse learns that although Angela blurted out that she had been raped when she first came home, since then she has refused verbalization about the rape (“I don’t want to think or talk about it”), has stopped attending all college social activities (a marked change in behavior), and seems to be having nightmares. After analyzing the data, the nurse believes that Angela might be experiencing (2) rape-trauma syndrome: silent reaction. Fortunately, Angela trusts Annie and is willing to come to the student health center for help. A conversation with Angela confirms the nurse’s suspicions, and problem identification begins. The nurse talks further with Angela (3) to develop some treatment goals and formulate outcomes. The nurse also begins to think about the types of nursing interventions most likely to yield the desired outcomes. In the initial meeting with Angela, (4) the nurse encourages her expression of feelings and helps her to identify personal coping strategies and strengths. The nurse and Angela decide to meet in 1 week (5) to assess her progress toward achieving targeted outcomes. If she is not making progress, the care plan might need to be modified. (1) _____________________ (2) _____________________ (3) _____________________ (4) _____________________ (5) _____________________ a. b. c. d. a. b. c. d. a. b. c. d. a. b. c. d. e. f. 2. A female patient who is receiving chemotherapy for breast cancer tells the nurse, “The treatment for this cancer is worse than the disease itself. I’m not going to come for my therapy anymore.” The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? The nurse judges whether the patient database is adequate to address the problem. The nurse considers whether or not to suggest a counseling session for the patient. The nurse reassesses the patient and decides how best to intervene in her care. The nurse identifies several options for intervening in the patient’s care and critiques the merit of each option. 3. The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, “How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?” This demonstrates which characteristic of the nursing process? Systematic Interpersonal Dynamic Universally applicable in nursing situations 4. An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes “second nature” and “intuitive” once you start practicing. What thinking below should underlie the beginning nurse’s response? Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers. 5. The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. The nurse uses critical thinking skills to plan care for a patient. The nurse correctly administers IV saline to a patient who is dehydrated. The nurse assists a patient to fill out an informed consent form. The nurse learns the correct dosages for patient pain medications. The nurse comforts a mother whose baby was born with Down syndrome. The nurse uses the proper procedure to catheterize a female patient. 6. A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. a. It functions independently of nursing standards, ethics, and state practice acts. b. It is based on the principles of the nursing process, problem solving, and the scientific method. c. d. e. f. It is driven by patient, family, and community needs as well as nurses’ needs to give competent, efficient care. It is not designed to compensate for problems created by human nature, such as medication errors. It is constantly re-evaluating, self-correcting, and striving for improvement. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care. a. b. c. d. 7. A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? Patient-centered care Evidence-based practice Quality improvement Informatics a. b. c. d. 8. A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: Clinical judgment Clinical reasoning Critical thinking Blended competencies a. b. c. d. 9. A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? Travelbee’s Watson’s Benner’s Swanson’s a. b. c. d. 10. The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice p. 331 p. 332 ANSWERS WITH RATIONALES 1. (1) is an illustration of assessing: the collection of patient data. (2) is an illustration of the identification of a nursing diagnosis: a health problem that independent nursing intervention can resolve. (3) is an illustration of planning: outcome identification and related nursing interventions. (4) is an illustration of implementing: carrying out the care plan. (5) is an illustration of evaluating: measuring the extent to which Angela has achieved targeted outcomes. 2. c. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision. 3. b. Interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process. 4. a. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference. 5. a, d. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill. 6. b, c, e. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses’ needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve. 7. c. Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making. 8. a. Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients. 9. d. Swanson (1991) identifies five caring processes and defines caring as “a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility.” Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model, and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing. Watson’s theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted. 10.c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice. The Nursing Diagnosis – Chp 15 a. b. c. d. e. f. 1. A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. The nurse uses the nursing interview to collect patient data. The nurse analyzes data collected in the nursing assessment. The nurse develops a care plan for the patient. The nurse points out the patient’s strengths. The nurse assesses the patient’s mental status. The nurse identifies community resources to help his family cope. a. b. c. d. e. f. 2. A nurse is caring for a patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. Bronchial pneumonia Impaired gas exchange Ineffective airway clearance Potential complication: sepsis Infection related to pneumonia Risk for septic shock a. b. c. d. 3. After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? No problem Possible problem Actual nursing diagnosis Clinical problem other than nursing diagnosis a. b. c. d. 4. A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? Risk for Impaired Skin Integrity Related to prescribed bed rest As evidenced by As evidenced by reddened areas of skin on the heels and back 5. A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, “I don’t care what I look like anymore, I don’t even feel like washing my hair, let alone changing this bag.” The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? a. Collaborative problem b. c. d. a. b. c. d. a. b. c. d. a. b. c. d. Interdisciplinary problem Medical problem Nursing problem 6. The nurse records a patient’s blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? Compare this reading to standards. Check the taxonomy of nursing diagnoses for a pertinent label. Check a medical text for the signs and symptoms of high blood pressure. Consult with colleagues. 7. When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label “constipation.” What would be the instructor’s BEST response to this student’s diagnosis? “Was this diagnosis derived from a cluster of significant data or a single clue?” “This early diagnosis will help us manage the problem before it becomes more acute.” “Have you determined if this is an actual or a possible diagnosis?” “This condition is a medical problem that should not have a nursing diagnosis.” 8. A nurse makes a clinical judgment that an African American man in a stressful job is more vulnerable to developing hypertension than a White man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis? Actual Risk Possible Wellness 9. A nurse is writing nursing diagnoses for patients in a psychiatrist’s office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? a. b. c. d. a. b. c. d. Ineffective Coping related to inability to maintain marriage Defensive Coping related to loss of job and economic security Altered Thought Processes related to panic state Decisional Conflict related to placement of parent in a long-term care facility (1) and (2) (3) and (4) (1), (2), and (3) (1), (2), (3), and (4) 2. A nurse working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written as three-part nursing diagnoses? a. Disabled Family Coping related to lack of knowledge about home care of child on ventilator b. Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-lb weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height–weight charts c. Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments “I cannot do this,” “I know I’ll harm her because I’m not a nurse,” and “I can’t do medical things” a. b. c. d. d. Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as “How could God do this to me?” “I don’t deserve this,” “I don’t understand. I’ve tried to live my life well,” and “How could God make me suffer this way?” e. Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver’s loss of weight and clinical depression (1) and (3) (2) and (4) (1), (2), and (3) (1), (2), (3), (4), and (5) ANSWERS WITH RATIONALES 1. b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process. 2. b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and “potential complication: sepsis” is a collaborative problem. 3. b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion “no problem” means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem. 4. b. “Related to prescribed bed rest” is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. “Risk for Impaired Skin Integrity” is the problem, and “as evidenced by reddened areas of skin on the heels and back” are the defining characteristics of the problem. 5. d. Altered Health Maintenance is a nursing problem, because the diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies. 6. a. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient’s blood pressure reading, appropriate standards include normative values for the patient’s age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis. 7. a. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. A data cluster is a grouping of patient data or cues that point to the existence of a patient health problem. There may be a reason for the lack of a bowel movement for 2 days, or it might be this person’s normal pattern. 8. b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis. 9. d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause. 10.b. (1) is a two-part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement which blames home health aides for the patient’s problem. Statements that may be interpreted as libel or that imply nursing negligence are legally hazardous to all the nurses caring for the patient. Assigning blame in the written record is problematic. Planning Nursing Care – Chp. 16 a. b. c. d. e. f. 1. A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. The nurse formulates nursing diagnoses. The nurse identifies expected patient outcomes. The nurse selects evidence-based nursing interventions. The nurse explains the nursing care plan to the patient. The nurse assesses the patient’s mental status. The nurse evaluates the patient’s outcome achievement. a. b. c. d. e. f. 2. A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. A nurse sits down with a patient and prioritizes existing diagnoses. A nurse assesses a woman for postpartum depression during routine care. A nurse plans interventions for a patient who is diagnosed with epilepsy. A busy nurse takes time to speak to a patient who received bad news. A nurse reassesses a patient whose PRN pain medication is not working. A nurse coordinates the home care of a patient being discharged. a. b. c. d. 3. The nurse is helping a patient turn in bed and notices the patient’s heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? Initial planning Standardized planning Ongoing planning Discharge planning 4. A nurse is prioritizing the following patient diagnoses according to Maslow’s hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction a. b. c. d. a. b. c. d. e. f. a. b. c. d. a. b. c. d. a. b. c. d. Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow’s model? 2, 4, 1, 3 3, 1, 4, 2 2, 4, 3, 1 3, 2, 4, 1 5. A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. The nurse uses a minimal practice standard and is able to alter care to meet the patient’s individual needs. The nurse uses a binary decision tree for stepwise assessment and intervention. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. The nurse uses a decision tree that provides intense specificity and no provider flexibility. 6. A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. By 6/19/20, the patient’s ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in). By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer. 7. A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself. Following physical therapy, patient will begin to gradually participate in walking/running events. By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events. 8. A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? Offer the patient 60-mL fluid every 2 hours while awake. During the next 24-hour period, the patient’s fluid intake will total at least 2,000 mL. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20. At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day. a. b. c. d. 9. A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? Actual Possible Risk Collaborative a. b. c. d. 10. A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the “concepts” that are being diagrammed in this plan? Protocols for treating the patient problem Standardized treatment guidelines The nurse’s ideas about the patient problem and treatment Clinical pathways for the treatment of sickle cell anemia ANSWERS WITH RATIONALES 1. b, c, d. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the nursing care plan. Although all these steps may overlap, formulating and validating nursing diagnoses occur most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process. 2. b, d, e. Informal planning is a link between identifying a patient’s strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged. 3. c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home. 4. a. 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow’s hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need. 5. a, c. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-andeffect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research. 6. d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient’s achievement of new skills; and (c) is an outcome describing a physical change in the patient. 7. a. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person’s ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone’s ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes. 8. b. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: “Offer the patient 60-mL fluid every 2 hours while awake.” Correct: “The patient will drink 60-mL fluid every 2 hours while awake, beginning 1/3/20.” The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include “know,” “understand,” “learn,” and “become aware.” 9. b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions. 10.c. A concept map care plan is a diagram of patient problems and interventions. The nurse’s ideas about patient problems and treatments are the “concepts” that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient’s situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.