Download NCLEX Questions For Nursing 102 Exam #2 With Complete Answers. and more Exams Nursing in PDF only on Docsity!
NCLEX Questions For Nursing 102
Exam #2 With Complete Answers
A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. A. Pain is whatever the health care provider treating the pain says it is B. Pain exists whenever the person experiencing it says it exists C. Pain is an emotional and sensory reaction to tissue damage D. Pain is a simple, universal, and easy to describe phenomenon E. Pain that occurs without a known cause is psychological in nature F. Pain is classified by duration, location, source, transmission, and etiology - ANSWER B, C, F. Margo McCaffery offers the classic definition of pain that is probably of greatest benefit to nurses and their patients, "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" (1968, p. 95). The International Association for the Study of Pain (IASP) further defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP, 2014b). Pain is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. Pain is present whenever a person says it is, even when no specific cause of pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology A nurse is monitoring patients in a hospital setting for acute and chronic pain. Which patients would most likely relieve analgesics for chronic pain from the nurse? Select all that apply. A. A patient is receiving chemotherapy for bladder cancer B. An adolescent is admitted to the hospital for an appendectomy C. A patient is experiencing a ruptured aneurysm D. A patient who has fibromyalgia requests pain medication E. A patient has back pain related to an accident that occurred last year F. A patient is experiencing pain from second degree burns - ANSWER A, D, E. Chronic pain is pain that may be limited, intermittent, or persistent bu that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns A Patient reports abdominal pain that is difficult to localize. The nurse documents this as which type of pain?
A. Cutaneous B. Visceral C. Superficial D. Somatic - ANSWER B. The patients pain would be categorized as visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. A patient who is having a myocardial infraction reports pain that is situated in the neck. The nurse documents this as what type of pain? A. Transient pain B. Superficial pain C. Phantom pain D. Referred pain - ANSWER D. Referred pain is perceived in an area distant from its point of origin, whereas transient pain is brief and passes quickly. Superficial pain originated in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically The three types of responses to pain are physiologic, behavioral and affective. Which are examples of behavioral responses to pain? Select all that apply. A. A patient cradles a wrist that was injured in a car accident B. A child is moaning and crying due to a stomachache C. A patients pulse is increased following a myocardial infraction D. A patient in pain strikes out at a nurse who attempts to provide a bath E. A patient who has chronic cancer pain is depressed and withdrawn F. A child pulls away from a nurse trying to give an injection - ANSWER A, B, F. Protecting or guarding a painful area, moaning and crying, and moving away from painful stimuli are behavioral responses. Examples of a physiologic or involuntary response would be increased blood pressure or dilation of pupils. Affective responses such as anger, withdrawal, and depression, are psychological in nature A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors? A. an older adult on bedrest following cervical spine surgery B. a patient with a severe sunburn being treated for dehydration C. an industrial worker who has burns caused by a caustic acid D. a patient experiencing cardiac disturbances from an electrical shock - ANSWER A. Receptors in the skin and superficial organs may be stimulated
large nerve fibers to close the gate and block pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control theory The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the BEST tool to use with this patient? A. CRIES scale B. COMFORT scale C. FLACC scale D. FACES scale - ANSWER A. The CRIES pain scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiological factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC scale (F-faces, L-legs, A-activity, C-cry, C-consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES scale is used for children who can compare their pain to the faces depicted on the scale When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse is aware that the patient has consistently refused pain medication. What would be a priority nursing diagnosis for this patient? A. Acute Pain related to fear of taking prescribed postoperative medications B. Impaired Physical Mobility related to surgical procedure C. Anxiety related to outcome of surgery D. Risk for Infection related to surgical incision - ANSWER A. The patients immediate problem is the pain that is unrelieved because the patent refuses to take pain medication for an unknown reason. The other nursing diagnoses are plausible, but not a priority in this situation When developing the care plan for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain not related to cancer or palliative/end of life care is not effectively relieved through which method? A. Using the highest effective dose of an opioid on a PRN (as needed) basis B. Using nonopijoid drugs conservatively C. Using consistent nonpharmacologic and nonopijoid pharmacologic therapies D. Administering a continuous intravenous infusion on a regular basis - ANSWER C. Nonpharmacologic and nonopijoid pharmacologic therapies are the preferred choices for chronic pain that is not related to active cancer, palliative care, or end of life care. If profession to opioids become necessary, the lowest effective dose of an immediate release opioid should be initiated first. Ongoing assessment and careful monitoring should guide the
prescription of opioids for the management of chronic pain (Dowell et al., 2016). A PEN (as needed) drug regimen has not been proven effective for people experiencing chronic or acute pain. In the early postoperative period, when pain is expected, this protocol may result in an intense pain experience for the patient. Later, however, in the postoperative course, a PRN schedule may be acceptable to relieve occasional pain episodes When assessing pain in a child, the nurse needs to be aware of what considerations? A. Immature neurologic development results in reduced sensation of pain B. Inadequate or inconsistent relief of pain is widespread C. Reliable assessment tools are currently unavailable D. Narcotic analgesic use should be avoided - ANSWER B. Health care personnel are only now becoming aware of pain relief as a priority for children in pain. The evidence supports the fact that children do indeed feel pain and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of what side effect? A. Pruritus B. Urinary retention C. Vomiting D. Respiratory depression - ANSWER D. Too much of an opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritus, urinary retention, and vomiting may occur but are not life threatening A nurse is assessing a patient receiving a continuous opioid infusion. For which related condition would the nurse immediately notify the primary care provider? A. A respiratory rate of 10/min with normal depth B. A sedation level of 4 C. Mild confusion D. Reported constipation - ANSWER B. Sedation level is more indicative of respiratory depression because a drop in level usually precedes it. A sedation level of 4 calls for immediate action because the patient has minimal or no response to stimuli. A respiratory level of 10 with normal depth of breathing is usually not a cause for alarm. Mild confusion may be evident with the initial dose and then disappear; additional observation is necessary. Constipation should be reported to the health care provider, but is not the priority in this situation
E. A patient joins a gym and schedules classes throughout the year. F. A patient proudly displays his certificate for completing a marathon. - ANSWER B, F. Prizing something one values involves pride, happiness, and public affirmation, such as losing weight or running a marathon. When choosing, one chooses freely from alternatives after careful consideration of the consequences of each alternative, such as quitting smoking and working fewer hours. Finally, the person who values something acts on the value by combining choice and behavior with consistency and regularity, such as joint a gym for the year and following a low cholesterol diet faithfully. A nurse incorporates the "five values that epitomize the caring professional nurse" (identified by the American Association of Colleges of Nursing) into a home health care nursing practice. Which attribute is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice? A. Altruism B. Autonomy C. Human dignity D. Integrity - ANSWER D. The American Association of Colleges of Nursing defines integrity as acting in accordance with an appropriate code of ethics and accepted standards of practice. Altruism is a concern for the welfare and well-being of others. Autonomy is the right to self-determination, and human dignity is respect for the inherent worth and uniqueness of individuals and populations A nurse caring for patients in an institutional setting expresses a commitment to social justice. What action best exemplifies this attribute? A. Providing honest information to patients and the public B. Promoting universal access to health care C. Planning care in partnership with patients D. Documenting care accurately and honeslty - ANSWER B. The American Association of Colleges of Nursing lists promoting universal access to health care as an example of social justice. Providing honest information and documenting care accurately and honeslty are examples of integrity, and plan Ning care in partnership with patients is an example of autonomy An older nurse asks a younger coworker why the new generation of nurses just aren't ethical anymore. Which reply reflects the BEST understanding of moral development? a. "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code." b. "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!" c. "Ethics is genetically determined...it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had."
d. "I agree! It's impossible to be ethical when working in a practice setting like this!" - ANSWER A. The ability to be ethical, to make decisions, and to act in an ethically justified manner begins in childhood and develops gradually A home health nurse performs a careful safety assessment of the home of a frail older adult to prevent harm to the patient. The nurse's action reflects which principle of bioethics? A. Autonomy B. Beneficence C. Justice D. Fidelity E. Nonmaleficence - ANSWER E. Nonmaleficence is defined as the obligation to prevent harm. Autonomy is respect for another's right to make decisions, beneficence obligates use to benefit the patient, justice obligates us to act fairly, and fidelity obligates us to keep our promises A hospice nurse is caring for a patient with end-stage cancer. What action demonstrates this nurse's commitment to the principle of autonomy? A. The nurse helps the patient prepare a durable power of attorney document B. The nurse gives the patient undivided attention when listening to concerns C. The nurse keeps a promise to provide a counselor for the patient D. The nurse competently administers pain medication to the paitent - ANSWER A. The principle of autonomy obligates nurses to provide information and support patients and their surrogates need to make decisions that advance their interests. Acting with justice means giving each person his or her due, acting with fidelity involves keeping promises to patients, and acting with nonmaleficence means avoiding doing harm to patients A nurse wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. The nurse believes his dying is being prolonged painfully. The patient's doctor threatens the nurse with firing if the nurse raises questions about the patient's care or calls the consult. What ethical conflict is this nurse experiencing? A. Ethical uncertainty B. Ethical distress C. Ethical dilemma D. Ethical residue - ANSWER B. Ethical distress results from knowing the right thing to do but finding it almost impossible to execute because of institutional or other constraints (in this case, the nurse fears the loss of job). Ethical uncertainty results from felling troubled by a situation but not knowing if it is an ethical problem. Ethical dilemmas occur when the principles of bioethics justify two or more conflicting courses of action.
F. Medicare reimbursement - ANSWER A, D. Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state nurse practice act. Nurse practice acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing medicare reimbursement are enacted through federal legislation A nurse in a NICU fails to monitor a premature newborn according to the protocols in place, and is charged with malpractice. What is the term for those brining the charges against the nurse? A. Appellates B. Defendants C. Plaintiffs D. Attorneys - ANSWER C. The person or government bringing suit against another is called the plaintiff. Appellates are courts of law, defendants are the ones being accused of a crime or tort, and attorneys are the lawyers representing both the plaintiff and defendant A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a patient's vital signs during routine eye surgery, leading to the death of the patient. The nurse's attorney explained in court that the nurse was granted recognition in a specialty area of nursing. What is the term for this type of credential? A. Accreditation B. Licensure C. Certification D. Board approval - ANSWER C. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing Review of a patient's record revealed that no one obtained informed consent for the heart surgery that was performed on the patient. Which intentional tort has been committed? A. Assault B. Battery C. Invasion of privacy
D. False imprisonment - ANSWER B. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact but another person unless consent is granted. The fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute fake imprisonment A veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75 year old woman who died after slipping into a coma during routine outpatient hernia surgery. The nurse admitted failing to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, stating that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. What criteria must be established to prove that the nurse is guilty of malpractice or negligence in this case? A. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient should not have died B. The fact that this patient should not have died since she was a health grandmother of 10, who was physically active and involved - ANSWER D. Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse- patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Damages are the actual harm or injury resulting to the patient An attorney is representing a patient's family who is suing a nurse for wrongful death. The attorney calls the nurse and asks to talk about the case to obtain a better understanding of the nurse's actions. How should the nurse respond? A. "I'm sorry, but I can't talk with you; you will have to contact my attorney" B. "I will answer your questions so you'll understand how the situation occurred" C. "I hope I won't be blame for the death because it was so busy that day" D. "First tell me why you are doing this to me. This could ruin my career!" - ANSWER A. The nurse should not discuss the case with anyone at the facility (with the exception of the risk manager), with the plaintiff, with the plaintiff's lawyer, with anyone testifying for the plaintiff, or with reporters. This is one of the cardinal rules for sure defendants
C. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor D. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary - ANSWER B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages int he event of patient injury if an assignment called for clinical skills beyond a students competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene? A. When the patient had his or her most recent bath B. The patients usual hygiene practices and preferences C. Where the bathing fits in the nurse's Schedule D. The time that is convenient for the patient care assistant - ANSWER B. Bathing practices and cleaning habits and rituals vary widely. The patients preferences should plays be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patients personal hygiene. The availability of staff to assist may be important, but the patients preference are a higher priority A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. A. It promotes the patients sense of wellbeing B. It prevents deterioration of the oral cavity C. It contributes to decreased incidence of aspiration pneumonia D. It eliminates the need for flossing E. It decreases oropharyngeal secretions F. It helps to compensate for an inadequate diet - ANSWER A, B, C. Adequate oral hygiene is essential for promoting the patients sense of well-being and presenting deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal recreations, decreasing the incidence of aspiration pneumonia and other systemic disease. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition
A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always "itchy" Which nursing action would be the nurses best response? A. Bathe the patient more frequently B. Use an emollient on the dry skin .C. Massage the skin with alcohol D. Discourage fluid intake - ANSWER B. An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry skin A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. A. A patient who is taking antibiotics for chronic bronchitis B. A patient diagnosed with type 2 diabetes C. A patient who is obese D. A patient who has a nervous habit of biting his nails E. A patient diagnosed with prostate cancer F. A patient whose job involves frequent handwashing - ANSWER B, C, D, F. Variables known to cause nail and foot problems include deficient self care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. A. Compare bilateral parts for symmetry. B. Proceed in a toe-to-head systematic manner. C. Use standard terminology to report and record findings. D. Do not allow data from the nursing history to direct the assessment. E. Document only skin abnormalities on the patient record. F. Perform the appropriate skin assessment when risk factors are identified. - ANSWER A, C, F. When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head to toe systematic manner, and allow date from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply.
A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient's eyes? A. Use hydrogen peroxide on a clean washcloth to wipe the eyes B. Wipe the eye from the outer canthus to the inner canthus C. Position the patient on the opposite side of the eye to be cleansed D. Cleanse the eye using a different section of the cleaning cloth for each stroke until clean - ANSWER D. When cleaning the eyes, the nurse should wear gloves during the cleaning procedure, use water or normal saline, and a clean washcloth or compress to clean the eyes. The nurse should dampen a cleaning cloth with the solution of choice and wipe once while moving from the inner canthus to the outer canthus of the eye. This technique minimizes the risk for forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleaning cloth and use a different section for each stroke until the eye is clean. A nurse is providing foot care for patients in a long term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. A. Bathe the feet thoroughly in a mild soap and tepid water solution B. Soak the feet in warm water and bath oil C. Dry feet throughly, including the area between the toes D. Use an alcohol rub if the feet are dry E. Use an anti fungal foot powered if necessary to prevent fungal infections F. Cute the toenails at the lateral corners when trimming the nail - ANSWER A, C, E. The following are recommended guidelines for foot care: bathe the feet throughly in a mild soap and tepid water solution; dry feet throughly, including the area between the toes; and use an anti fungal foot powered if necessary to precent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure? A. Shift the focus of the interaction to the "process of bathing" B. Wash the fact and hair at the beginning of the bath C. Consider using music to soothe anxiety and agitation D. Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar - ANSWER C. The nurse should consider the use of music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. The nurse should wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with
dementia. The nurse should also consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options A nurse is teaching a student nurse how to cleanse the perineal area of bath male and female patients. What are accurate guidelines when performing this procedure? Select all that apply. A. For male and female patients, wash the groin area with a small amount of soap and water and rinse B. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area C. For male and female patients, always proceed from the most contaminated area to the least contaminated area D. For male and female patients, use a clean portion of the washcloth for each stroke E. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward F. In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis - ANSWER A, D, E. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from he least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the time of the penis first, moving the washcloth in a circular motion from he meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin while washing the penis A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? A. Add bath oil to the water to prevent dry skin B. Allow the patient to lock the door to guarantee privacy C. Assist the patient in and out of the tub to precent falling D. Keep the water temperature very warm because older adults chill easily - ANSWER C. Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha Keri oil to the bath water is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortable warm at 43 to 46 degrees Celsius. Older adults have an increased susceptibility to burns due to diminished sensitivity A nurse is bout to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the
(3) planning: outcome identification and related nursing interventions (4) implementing: carrying out the care plan (5) evaluation: measuring the extent to which Angela has achieved target outcomes 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? A. The nurse judges whether the patient database is adequate to address the problem B. The nurse considers whether or not to suggest a counseling session for the patient C. The nurse reassesses the patient and decides how best to intervene in her care D. The nurse identifies several options for intervening in the patients care and critiques the merit of each option - ANSWER 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 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? A. Systematic B. Interpersonal C. Dynamic D. Universally applicable in nursing situations - ANSWER 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 An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reading becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? A. Intuitive problem solving comes with years of practice and observation, and nonie nurses should base their care on scientific problem solving B. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning
C. The emphasis on logical, scientific, evidence based reasoning has held nursing back for years; it it time to champion intuitive, creative thinking! D. It it simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers - ANSWER 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 The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all the apply. A. The nurse uses critical thinking skills to plane care for a patient B. The nurse correctly administers IV saline to a patient who is dehydrated C. The nurse assists a patient to fill out an informed consent form D. The nurse learns the correct dosages for patient pain medications E. The nurse comforts a mother whose baby was born with down syndrome F. The nurse uses the proper procedure to catheterize a female patient - ANSWER 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 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. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. D. It is not designed to compensate for problems created by human nature, such as medication errors. E. It is constantly re-evaluating, self-correcting, and striving for improvement. F. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care. - ANSWER 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.
