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Keiser BSN Clinical Decision Making
Quiz Chapters 1-3 QUESTIONS WITH
ANSWERS
What are the primary goals of nursing - CORRECT ANSWERS ✔✔1)determine/family responses to human procedure
- providing physical care, emotional care, teaching, guidance, and counseling
- implement intervention aimed at prevention and assisting the clients to meet his always focus on assisting clients and families to their highest level of functioning What does the nursing process involve - CORRECT ANSWERS ✔✔ADPIE ADPIE - CORRECT ANSWERS ✔✔Assessment Diagnosis Planning Implementation Evaluation Patient Story Includes: - CORRECT ANSWERS ✔✔subjective and objective
Assessment is for - CORRECT ANSWERS ✔✔appropriate diagnosis, planning and intervention Assessment is completed - CORRECT ANSWERS ✔✔thorough health and medical history, by listening to and observing the client and asking open ended question information is obtained by performing - CORRECT ANSWERS ✔✔a physical assesment, taking vital signs, and noting diagnostic test results One phase of diagnosis - CORRECT ANSWERS ✔✔1) clustering information The process of thinking in the diagnostic process is - CORRECT ANSWERS ✔✔clinical reasoning clinical reasoning - CORRECT ANSWERS ✔✔a cognitive process that uses formal and informal thinking strategies to gather and analyze client inforfmation, evaluate the signifcance of this information, and determine the value of alternative action Once a diagnosis is established what is the next step - CORRECT ANSWERS ✔✔to determine related factors and defining characteristic
define problem focused diagnosis - CORRECT ANSWERS ✔✔a clinical judgement concerning an undesireable human response to a health condition/life process that exists in an individual, family, group or community. Ex) Iverweight related to an excessive intake relation to metabolic needs, concentrating food intake at the end of the day aeb weight 20% over ideal for their height and frame. risk nursing diagnosis - CORRECT ANSWERS ✔✔a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes Ex) RIsk for overweight: risk factor contating food at the end of the day health promotion diagnosis - CORRECT ANSWERS ✔✔a clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential Ex) enhancing and emphasizing nutrition health promotion is - CORRECT ANSWERS ✔✔always associated with a positive intervention Case study: A 73 year old man has been admitted to the unit with a dx of COPD. He states that he has difficulty breathing when walking short distances. He
also states that his heart feels like it is racing. BPM 110. He states that he is tired all the time and while he is talking he is wringing his hands. What is your first step - CORRECT ANSWERS ✔✔List the symptoms Case study: A 73 year old man has been admitted to the unit with a dx of COPD. He states that he has difficulty breathing when walking short distances. He also states that his heart feels like it is racing. BPM 110. He states that he is tired all the time and while he is talking he is wringing his hands. What's your second step - CORRECT ANSWERS ✔✔Cluster symptoms Case study: A 73 year old man has been admitted to the unit with a dx of COPD. He states that he has difficulty breathing when walking short distances. He also states that his heart feels like it is racing. BPM 110. He states that he is tired all the time and while he is talking he is wringing his hands. Step 3 & Step 4 - CORRECT ANSWERS ✔✔Analyze, interpret subjective symptoms Analyze, interpret objective symptoms Case study: A 73 year old man has been admitted to the unit with a dx of COPD. He states that he has difficulty breathing when walking short distances. He also states that his heart feels like it is racing. BPM 110. He states that he is tired all the time and while he is talking he is wringing his hands.
Interventions - CORRECT ANSWERS ✔✔identified as independent or collaborative Ex) teaching is independent Ex) doctor's orders for a patient is a road map guide to nursing care Most important actions of a care plan is - CORRECT ANSWERS ✔✔documentation implementation - CORRECT ANSWERS ✔✔carrying out the plan of care, performing the nursing interventions, delegating the appropriate nursing interventions evaluation - CORRECT ANSWERS ✔✔was the patient outcome completed, what do you do if the patient did not reach their outcome - CORRECT ANSWERS ✔✔reassess the care plan, make a new patient goal that the paitent may be able to attain Conceptual Mapping - CORRECT ANSWERS ✔✔an active learning strategy that promotes clinical thinking and clinical judgement , and helps increasing clinical competency
critical thinking - CORRECT ANSWERS ✔✔requries lifelong learning and the ability to acquire relevant experiences that can be reflected on continuously improving nursing judgement. Critical thinking follows a systmatic process Components: knowledge, attitudes, experience, critical thinking competencies, and intellectual and profession standards. Levels of Clinical thinking - CORRECT ANSWERS ✔✔Basic- A nurse trusts the experts and thinks concretely based on the rules. Results from limited nursing knowledge and expierence, as well as, inadequate critical thinking experience Complex critical thinking : The nurse begins to express autonomy by analyzing and examining data to determine the best alternative. Results from an increase in nursing knowledge, experience, intutition, and more flexible attitudes Commitment: The nurse expects to make choices without help from others and fully assumes the responsibility for those choices. Results from expert level of of knowledge,intuition, experience and reflective flexible attitudes Attitudes of critical thinking - CORRECT ANSWERS ✔✔1)confidence- Feels sure about abilities
- independence- analyzes ideas for logial reasoniinf
- fairness- is objective, nonjudgemental
- responsibility- Adheres to standard of practice
- A client with congestive heart failure is having difficulty breathing. Before leaving the room the nurse ensures the client has an over-bed table to lean on when awake if needed to ease breathing. Which technique did the nurse use to make this decision? A) Delegating a task B) Priority-setting C) Conflict resolution D) Critical thinking - CORRECT ANSWERS ✔✔Answer D ) A postoperative client prescribed pain medication every 4 to 6 hours is requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a rating scale of 1 to 10. The nurse decides to give the pain medication now. What does this nurse's action exemplify? A) Meeting a client goal B) Time management skills C) Prioritizing the client's care D) A response to a change in the client's condition - CORRECT ANSWERS ✔✔Answer D By the second post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process A. Assess the client to determine the reasons for inadequate pain relief B. Wait to see whether the pain lesssens during the next 24hrs C. Change the plan of care to provide different pain relief interventions
D. Teach the cleint about the plan of care for managing the pain - CORRECT ANSWERS ✔✔Answer: A The nurse is assigned two clients. One client needs postoperative teaching in preparation for discharge and the other client with pneumonia has a PaCO2 of 85. Why does the nurse decide to see the client with pneumonia first?A) The nurse can delegate postoperative teaching to unlicensed assistive personnel (UAP). B) The client with pneumonia needs more care than the client needing postoperative teaching. C) The client with pneumonia may be experiencing respiratory distress. D) The room of the client with pneumonia is closer than that of the client needing postoperative teaching. - CORRECT ANSWERS ✔✔Answer A A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6hrs ago. THe prescription reads every 4 hours prn for pain. The nurse administered the medication and checked with the client 40minutes later, when the client reported imporvement. The newly licensed nurse left with out which of the following steps in the nursing process A. Assessment B. Planning C. Intervention D. Evaluation - CORRECT ANSWERS ✔✔Answer A
A. Basic B. Commitment C. Complex D. Integrity - CORRECT ANSWERS ✔✔Answer: A A nurse recieves a prescription for an antiobiotic for a ptwho has cellulitis. THe nurse checks the client's medical record, discovers that tthe client is allergic to the antibiotic, and calls the provider to request a Rx for a different antibiotic. What critical thinking attitude did the nurse demonstrate? A. Fairness B. Responsibility C. Risk-taking D. Creativity - CORRECT ANSWERS ✔✔Answer: B A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? Select all that apply A. Find a mentor B. Use a journal to write about the outcomes of clinical judements C. Review articles about evidence based practice D. Limit consultations with other professionals involved in a client's care E. Make quick decisions when unsure about a client's needs - CORRECT ANSWERS ✔✔Answers: A, B, C
- A client seen in an urgent care clinic is complaining of abdominal pain and believes that the food eaten the previous evening was tainted. What should the nurse do after the client states that the food was tainted? A) Ask the client open-ended questions to further assess the situation. B) Tell the client the physician does not need to assess the client. C) Call an ambulance before assessing the client any further. D) Advise the client to take an antacid. - CORRECT ANSWERS ✔✔Answer: A
- A client with aspiration pneumonia is diaphoretic, pale, and taking gasping breaths. What should the nurse do first? A) Notify the physician. B) Complete a thorough cardiopulmonary assessment. C) Administer 10 L of oxygen per face mask. D) Reposition the client to help with breathing. - CORRECT ANSWERS ✔✔Answer: B The home health nurse is visiting a client who is 2 weeks postoperative from a coronary artery bypass surgery. The client has lost 10 pounds, is continuing to experience pain, and is not eating. What should be the nurse's next action? A) Examine the current interventions for pain relief. B) Refer the client to social services. C) Contact Meals on Wheels so that the client will eat. D) Revise the goals in the current plan of care. - CORRECT ANSWERS ✔✔Answer: A
A conceptual map begins with - CORRECT ANSWERS ✔✔a central theme or concept and then related information is diagrammed radiating from the center theme. conceptual mapping can be used for - CORRECT ANSWERS ✔✔determining outcomes and interventions Lines in a comceptual map show - CORRECT ANSWERS ✔✔relationships or associations when identifying a nursing diagnosis, you should do which of the following? Select All that Apply A. Use the medical diagnosis B. Ask the client to identify their diagnosis C. Verify the definition of the diagnosis D. Develop an individualized diagnosis E. Verify the defining characteristics of the diagnosis - CORRECT ANSWERS ✔✔Answers: C, D Why is it necessary to verify the selected nursign interventions - CORRECT ANSWERS ✔✔To ensure that the interventions are appropriate How do you verify the nursing interventions - CORRECT ANSWERS ✔✔Look at Section 3 of the NANDA book
Confidentiality - CORRECT ANSWERS ✔✔share only information that is of benefit to the nusing and medical team for planning care ALWAYS FOLLOW HIPPA Nursing Diagnosis - CORRECT ANSWERS ✔✔independent nursing practice knowledge to treat human responses to health problems Response to actual or potential health problems or life processes
