Fundamentals of Nursing 4e Delaune Ladner Test bank

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Fundamentals of Nursing 4e Delaune Ladner Test bank

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CHAPTER 5: CRITICAL THINKING, DECISION MAKING, AND THE NURSING PROCESS

MULTIPLE CHOICE

1. A group of nurses were discussing the nursing process and realized that the term process to describe nursing was first used in:
a.
1955 by Lydia Hall.
c.
1961 by Ida Orlando.
b.
1855 by Florence Nightingale.
d.
1967 by Yura and Walsh.

ANS: A
Lydia Hall first referred to nursing as a process in a journal article written in 1955, but it was not until the late 1960s that the term began to be widely used. Orlando in 1961 referred to the nursing process as a series of steps. Yura and Walsh identified the original four steps of the nursing process. Florence Nightingale did not refer to client care as being conducted through the use of the nursing process.

PTS: 1 DIF: Analysis REF: The Nursing Process: Historical Perspective

2. A seasoned nurse tells a colleague that she went to nursing school before nursing diagnosis existed. When was nursing diagnosis added as a separate and distinct step in the nursing process?
a.
1959
c.
1974
b.
1963
d.
1985

ANS: C
Even though the term nursing diagnosis was first used in 1953, it was not until after the first meeting of the North American Nursing Diagnosis Association, or NANDA, that nursing diagnosis was added as a separate and distinct step in the nursing process. Prior to this date, nursing diagnosis was included as a natural conclusion to the assessment step of the process. The other choices are incorrect.

PTS: 1 DIF: Analysis REF: The Nursing Process: Historical Perspective

3. The nurse is beginning to plan care for a newly admitted client. The nurse will apply which of the following steps in the nursing process?
a.
Assessment, planning, and evaluation
b.
Assessing, planning, implementing, and evaluating
c.
Assessment, analysis, planning, implementation, and evaluation
d.
Assessment, diagnosis, outcome identification and planning, implementation, and evaluation

ANS: D
Currently, the steps in the nursing process are assessment, diagnosis, outcome identification and planning, implementation, and evaluation. The previous steps were: assessing, planning, implementing, and evaluating. The other choices are incorrect.

PTS: 1 DIF: Application REF: The Nursing Process: Historical Perspective

4. The nurse is assessing a client. Which data are considered data from a primary source?
a.
The clients spouse tells the nurse the client seems upset.
b.
The client reports right lower quadrant pain.
c.
The physician describes the client as being overanxious.
d.
The lab report shows an elevated white cell count.

ANS: B
The client is considered as being the primary source of data. The choice that reflects the client as providing the data is the client reports right lower quadrant pain. The other choices are secondary sources of data.

PTS: 1 DIF: Analysis REF: Assessment

5. The nurse is documenting data provided from a client. Which of the following is an example of subjective data?
a.
The client states, My head hurts.
b.
The laboratory report shows an elevated white cell count.
c.
The client weighs 148 pounds.
d.
The nurse hears bilateral sounds.

ANS: A
Subjective data are gathered by interacting with the client and include feelings, perceptions, and concerns. An example of subjective data is the client states, my head hurts. The other choices are objective data and are incorrect.

PTS: 1 DIF: Application REF: Assessment

6. The nurse is measuring a clients vital signs. The data collected would be considered:
a.
subjective.
c.
irrelevant.
b.
objective.
d.
secondary.

ANS: B
Objective data are observable and measurable and are obtained through physical examination and diagnostic tests. An example of objective data is vital signs. Subjective data are gathered by interacting with a client and include feelings, perceptions, and concerns. Secondary is not a type of data but rather a source for data. Irrelevant is not a category of data within the assessment phase of the nursing process.

PTS: 1 DIF: Application REF: Assessment

7. The nurse is documenting information gained from the assessment of a client. Which of the following is an example of objective data?
a.
The client states, I have a headache.
b.
The client complains of a sore throat.
c.
The clients temperature is 100.4F.
d.
The client says he doesnt sleep well at night.

ANS: C
Objective data are observable and measurable and are obtained through physical examination and diagnostic tests. An example of objective data is vital signs or in this case, the clients temperature reading. The other choices are examples of subjective data and are incorrect.

PTS: 1 DIF: Application REF: Assessment

8. The nurse has completed the assessment of a client and is preparing to identify applicable nursing diagnoses. This step of the process includes:
a.
collection of data.
c.
organization of data.
b.
validation of data.
d.
analysis of data.

ANS: D
The second step in the nursing process involves further analysis and synthesis of the data collected during the assessment. Collection, validation, and organization of data all occur within the assessment phase of the nursing process.

PTS: 1 DIF: Application REF: Assessment| Diagnosis

9. The nurse is formulating an actual nursing diagnosis for a client. Which of the following is an example of an actual nursing diagnosis?
a.
Risk for impaired skin integrity related to inability to change positions
b.
Potential for enhanced nutrition
c.
Fluid volume deficit related to nausea and vomiting
d.
Risk for infection related to indwelling urinary catheter

ANS: C
An actual nursing diagnosis indicates that a problem exists and is composed of the diagnostic label, related factors, and signs and symptoms. The choice that fits this criteria would be Fluid volume deficit related to nausea and vomiting. Risk for impaired skin integrity and Risk for infection would be risk nursing diagnoses. Potential for enhanced nutrition would be a possible nursing diagnosis.

PTS: 1 DIF: Application REF: Types of Nursing Diagnoses

10. The nurse is analyzing data collected during a client assessment and wants to identify possible nursing diagnoses. A possible nursing diagnosis indicates:
a.
a situation in which a problem could arise unless preventive action is taken.
b.
that a problem does not yet exist, but special risk factors are present.
c.
the clients expression of a desire to attain a higher level of wellness in some area of function.
d.
that a problem exists.

ANS: A
A possible nursing diagnoses indicates a situation in which a problem could arise unless preventive action is taken. A problem that does not yet exist but has special risk factors present would be a risk nursing diagnosis. The clients expression of a desire to attain a higher level of wellness in some area of function would be a wellness nursing diagnosis. An actual problem existing would be an actual nursing diagnosis.

PTS: 1 DIF: Application REF: Types of Nursing Diagnoses

11. The nurse is establishing goals with a client. Which of the following best describes a goal?
a.
It is measurable and has a time limit.
b.
It is a broad statement that describes the intended change in the clients behavior or response.
c.
It is a direct result of analysis of collected data.
d.
It includes both objective and subjective data.

ANS: B
A goal is an aim, intent, or end. Goals are broad statements that describe the intended or desired change in the clients behavior. Expected outcomes are measurable and have a time limit. A nursing diagnosis is a direct result of analysis of collected data. Objective and subjective data are collected during the assessment.

PTS: 1 DIF: Application REF: Outcome Identification and Planning

12. The nurse is writing measurable expected outcomes for a client. Which of the following is an example of a measurable expected outcome?
a.
Turn, deep breathe, and cough every 2 hours.
b.
The client will maintain nutritional status.
c.
The client will walk the length of the corridor twice a day by the second day after surgery.
d.
The client has gained 3 pounds.

ANS: C
Expected outcomes are specific objectives related to the goals and are used to evaluate the nursing interventions. They must be measurable, have a time limit, and be realistic. The choice that fits this criteria is the client will walk the length of the corridor twice a day by the second day after surgery. Turn, deep breathe, and cough every 2 hours is an example of a nursing intervention. The client will maintain nutritional status is an example of a goal. The client has gained 3 pounds is an example of an evaluation of client care.

PTS: 1 DIF: Application REF: Outcome Identification and Planning

13. When creating nursing diagnoses for a client, which of the following should the nurse keep in mind?
a.
A nursing diagnosis is the same as a medical diagnosis.
b.
Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
c.
The focus should be on the illness, injury, or disease process.
d.
The diagnosis remains constant until a cure occurs.

ANS: B
A nursing diagnosis is not the same as a medical diagnosis. The focus on illness, injury, or disease process describes a medical diagnosis. The diagnosis remaining constant until a cure occurs describes a medical diagnosis. The correct choice is that nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

PTS: 1 DIF: Application
REF: Table 5-3 Comparison of Medical Diagnoses and Nursing Diagnoses

14. The nurse preparing to prioritize identified nursing diagnoses for a client. In which step of the nursing process does this activity occur?
a.
Assessment
c.
Outcome identification and planning
b.
Diagnosis
d.
Evaluation

ANS: C
During the outcome identification and planning phase of the nursing process, one activity is prioritizing the list of nursing diagnoses. This activity does not occur in the assessment diagnosis or evaluation phases and these choices are incorrect.

PTS: 1 DIF: Application REF: Outcome Identification and Planning

15. The nurse is identifying the types of data collected during the assessment of a client. Which of the following is an example of subjective data?
a.
Nausea
c.
Cyanosis
b.
Pulse of 62
d.
Facial grimace

ANS: A
Subjective data are gathered by interaction with the client and include feelings, perceptions, and concerns. Nausea is something that the client would express to the nurse. Pulse of 62 would be objective data. Cyanosis is objective data. Facial grimacing is also objective data.

PTS: 1 DIF: Application REF: Assessment

16. The nurse is reviewing data collected during the assessment of a client. To sufficiently analyze the data, the nurse will need to use critical thinking which involves:
a.
repeating memorized facts.
c.
acting immediately on data.
b.
finding meaning in facts.
d.
engaging in groupthink.

ANS: B
Critical thinking is a process that allows nurses to see the big picture instead of focusing on details. Finding meaning in the facts is the core of critical thinking. Critical thinking is not repeating memorized facts or acting immediately on data. Engaging in groupthink is a barrier to critical thinking.

PTS: 1 DIF: Application REF: Critical Thinking, Knowledge

17. The nurse is having difficulty with creative thinking. An example of a block to creative thinking is:
a.
fear of making a mistake.
c.
open mindedness.
b.
self-confidence.
d.
self-evaluation.

ANS: A
There are several blocks to creative thinking: habit, comfort with the status quo, fear of making mistakes, tradition, use of meaningless routines and rituals, and rigid mind-set. The other choices are characteristics of a critical thinker and are incorrect.

PTS: 1 DIF: Application REF: Critical Thinking and Creativity

18. The nurse is planning care for a client. A step carried out in the planning phase of the nursing process would include:
a.
taking the clients blood pressure and pulse.
b.
assisting the client with activities of daily living.
c.
identifying appropriate goals and outcomes for the client.
d.
inspecting the incision site for redness and drainage.

ANS: C
The planning phase of the nursing process involves several tasks, one of which is identifying appropriate goals and outcomes for the client. Taking the clients blood pressure and pulse and inspecting the incision site for redness and drainage would be done during the assessment phase of the process. Assisting the client with activities of daily living would be done during the implementation phase of the process.

PTS: 1 DIF: Application REF: Outcome Identification and Planning

19. The nurse conducts client care within the third stage of relativism. According to Perry, a person has developed to the level of relativism in critical thinking when that person:
a.
is able to develop her own truth after evaluating information from several sources.
b.
has the ability to form opinions and values based on weighing information in situations.
c.
believes differences are in effect only until the right answer is discovered by experts.
d.
views the world in dichotomous terms.

ANS: B
According to Perry, there are four stages of cognitive development. Viewing the world in dichotomous terms describes stage 1 of dualism. Believing that differences are in effect only until the right answer is discovered by experts describes stage 2 of multiplicity. Having the ability to form opinions and values based on weighing information in situations describes stage 3 of relativism. Having the ability to develop truth after evaluating information from several sources describes stage 4 of commitment.

PTS: 1 DIF: Analysis REF: Table 5-1 Stages of Cognitive Development

20. The nurse is collecting assessment data on a newly admitted client. The nurse should immediately report assessment data to the physician when she:
a.
completes the assessment.
b.
identifies that the client is nervous and anxious about their illness.
c.
identifies vital signs that are outside the normal parameters for the clients age.
d.
is unsure whether data obtained is accurate.

ANS: C
The nurse must make a judgment about which data are to be reported immediately and which data need only to be recorded. Of the choices, vital signs that are outside the normal parameters for the clients age would need to be reported to the physician immediately. The other choices are incorrect and do not need to be reported to the physician immediately.

PTS: 1 DIF: Application REF: Assessment

21. The nurse is working within the fourth step of the nursing process, or implementation, which involves:
a.
validating and organizing data.
b.
analyzing and labeling data.
c.
identifying goals and outcomes for the client.
d.
performing or delegating nursing activities.

ANS: D
The fourth step in the nursing process, implementation, involves the execution of the nursing plan of care. It consists of performing nursing activities or delegating the activities to other persons assigned to care for the client. Validating and organizing data and analyzing and labeling data are done during the assessment phase of the process. Identifying goals and outcomes for the client is done during the outcome identification and planning phase of the process.

PTS: 1 DIF: Application REF: Implementation

22. The nurse is creating interventions for a client that are innovative and different. This nurse is demonstrating critical and creative thinking by:
a.
needing to learn each new situation at his own pace.
b.
following the status quo in order to provide safe care.
c.
looking to authority figures for the right answers.
d.
being able to transfer learning from one situation to another.

ANS: D
Critical and creative thinkers are able to transfer learning from one situation to another. The other choices are incorrect and should not be selected.

PTS: 1 DIF: Analysis REF: Critical Thinking and Creativity

23. The nurse has identified collaborative problems while creating a list of nursing diagnoses for a client. Collaborative problems are those problems that:
a.
are managed through the use of interventions prescribed by other health care practitioners.
b.
indicate the clients desire to attain a higher level of wellness.
c.
result from the nurses intuition that a problem could occur.
d.
indicates risk factors exist that will result in a problem if not managed.

ANS: A
Collaborative problems are defined as physiologic complications monitored by nurses to assess changes in client status. These problems are managed through the use of interventions prescribed by other health care practitioners and nurses. A wellness diagnosis indicates the clients desire to attain a higher level of wellness. A possible nursing diagnosis results from the nurses intuition that a problem could occur. A risk nursing diagnosis indicates risk factors that will result in a problem if not managed.

PTS: 1 DIF: Application REF: Types of Nursing Diagnoses

24. The nurse is working through the nursing process with a client. This process is a:
a.
linear process used to plan client care.
b.
framework for providing nursing care that involves overlapping steps.
c.
scientific method for problem solving in nursing.
d.
circular process with distinct steps.

ANS: B
The nursing process is the framework for providing profession, quality nursing care. The process is not linear but involves overlapping steps that build upon each other. A scientific method for problem solving in nursing is a part of critical thinking.

PTS: 1 DIF: Application REF: Overview of the Nursing Process

25. One nurse has been singled out as having outstanding critical thinking skills. Which of the following characteristics would this nurse most likely demonstrate?
a.
Comfort with the status quo
c.
Sense of curiosity
b.
Use of tradition
d.
Use of habit

ANS: C
One of the most important attitudes needed by a critical thinker is a sense of curiosity that allows the person to question assumptions upon which decisions are based. The other choices are blocks to creative and critical thinking.

PTS: 1 DIF: Application REF: Attitudes

26. In which of the following ways does creative thinking impact client care?
a.
It hinders the problem-solving process.
b.
It facilitates analysis and planning.
c.
It is needed for making decisions.
d.
It is the foundation for individualized client care.

ANS: D
Creative thinking is the foundation for individualized client care in that the nurse identifies unique needs of each client and develops interventions specific to those needs. Creative thinking enhances the problem-solving process. Analysis and planning is facilitated by critical thinking. Critical thinking is needed for decision making.

PTS: 1 DIF: Analysis REF: Critical Thinking and Creativity

27. The nurse is stating results, justifying procedures, and presenting arguments about an aspect of a clients care. Which of the following critical thinking skills is this nurse demonstrating?
a.
Interpretation
c.
Analysis
b.
Explanation
d.
Self-regulation

ANS: B
When stating results, justifying procedures, and presenting arguments, the nurse is demonstrating the critical thinking skill of explanation. Categorizing, decoding, and clarifying would be interpretation. Examining ideas, identifying, and analyzing arguments would be analysis. Self-examination and self-correction would be self-regulation.

PTS: 1 DIF: Application REF: Table 5-2 Critical Thinking Skills

28. The nurse is implementing care for a client. Which of the following skills would be the most important for the nurse to possess in order to change the clients leg wound dressing?
a.
Assessment
c.
Psychomotor
b.
Interpersonal
d.
Critical thinking

ANS: C
Implementation involves many skills. Assessment is done prior to and after the implementation of an intervention. Interpersonal skills are used when the nurse interacts with the client to collect data, teach, and offer support. Critical thinking skills enable the nurse to work through situations, ask appropriate questions, and make decisions about care. Psychomotor skills are used when performing procedures such as changing the dressing on a leg wound, administering medications, and assisting with range-of-motion exercises.

PTS: 1 DIF: Application REF: Implementation

29. While evaluating the outcomes of care for a client, the nurse determines that a goal for a client has been met. Which of the following should the nurse do?
a.
Reassess the situation.
b.
Modify the plan of care.
c.
Determine to either cease nursing activities or continue to maintain the outcome.
d.
Suggest the client be discharged.

ANS: C
When goals have been met, the nurse must decide whether nursing activities will cease or continue in order for the clients status to be maintained. When goals have been partially met or not met, the nurse would need to reassess the situation and/or modify the plan of care. The nurse should not suggest the client be discharged.

PTS: 1 DIF: Application REF: Evaluation

30. The nurse is planning for a clients discharge. The step of the nursing process that is utilized the most during this phase of care would be:
a.
assessment.
c.
evaluation.
b.
implementation.
d.
nursing diagnosis.

ANS: C
Evaluation is an essential component of discharge planning that allows the nurse to work with clients and families in deciding whether further health care is needed and then providing necessary referrals. Although discharge planning should begin upon admission, the other steps are not utilized as much as evaluation during discharge planning.

PTS: 1 DIF: Application REF: Evaluation

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