Deck 11: Developing Nursing Judgment Through Critical Thinking

Question 1

Why is the etiology of the nursing diagnosis statement important?

A) If the etiology is incorrect, the nursing interventions are likely to be ineffective.
B) The etiology will be the same each time the nursing diagnosis is identified.
C) The etiology is necessary to identify the defining characteristics.
D) The etiology determines whether the problem can be solved.

Answer 1

If the etiology is incorrect, the nursing interventions are likely to be ineffective.

Question 2

Which of the following is considered objective data obtained from the patient?

A) "I can't catch my breath."
B) Patient expresses concern about missing work.
C) Patient nods, indicating an affirmative answer to a question.
D) Blood pressure is 110/70 at 8 p.m.

Answer 2

Blood pressure is 110/70 at 8 p.m.

Question 3

The identification of nursing diagnosis and goal setting should ideally be a collaborative process between the nurse and which other party?

A) Physician
B) Nurse manager
C) Patient's family
D) Patient

Answer 3

Patient

Question 4

Which of the following patient problems is given the highest priority by the nurse?

A) Anxiety related to hospitalization as manifested by hyperactive state
B) Impaired tissue perfusion, cerebral, related to hypoxia as manifested by decreased level of consciousness
C) Impaired skin integrity related to surgical incision
D) Risk for fluid volume overload related to imbalance in antidiuretic hormone as manifested by peripheral edema and decreased sodium

Question 5

Which of the following statements describes the purpose of the nursing process?

A) Process of documentation designed to decrease liability
B) Process designed to maximize reimbursement potential
C) A sophisticated time-management strategy
D) Process used to identify and solve patient problems

Question 6

A nursing student is complaining about writing care plans.Which response by the faculty is best to help the student see the importance of this activity?

A) "Using the nursing process will help nurses get reimbursement for their services."
B) "You need a written plan of care so everyone is on the same page as you are."
C) "The nursing process is a way to systematically think about and use patient data."
D) "Most state nurse practice acts require them, so you need to learn how to do them."

Question 7

Which of the following is a characteristic of an accomplished critical thinker?

A) Inquisitiveness
B) Narrow focus
C) Unaffected by other arguments
D) Quick decision making

Question 8

A patient is admitted with the diagnosis of bronchitis,congestive heart failure,and fever.The nurse's assessment finds a temperature of 101° F,peripheral edema,and rhonchi.Which of the following is the best etiology to support the nursing diagnosis of ineffective airway clearance?

A) Peripheral edema
B) Retained secretions
C) Bronchitis
D) Congestive heart failure

Question 9

A nursing student asks a faculty member how to improve critical thinking.Which response by the faculty is best?

A) "Don't worry too much; it will come with time and experience."
B) Pay close attention to how you solve problems; assess your own style of thinking."
C) "Spend time shadowing an experienced nurse to see how it is done."
D) "Use ethical standards to guide how you approach patient situations."

Question 10

What is the primary method of obtaining patient data?

A) Medical record
B) Speaking with family
C) Interview with patient
D) Physical examination

Question 11

The nurse observes a patient lying rigidly in bed and taking shallow breaths.The patient reports a pain score of 4 out of 5 and says,"My leg hurts." The nurse determines that the objective and subjective data are

A) incongruent and require more assessment.
B) insufficient to make any conclusions.
C) congruent and support that the patient is in pain.
D) unclear; the nurse needs to talk to the patient's family for more information.

Question 12

A nurse is admitting a non-English speaking patient to the hospital unit.Which is the best method of obtaining data from the patient?

A) Asking the other family members to help interpret
B) Performing a physical examination on the patient
C) Interviewing the patient using a professional interpreter
D) Attempting to obtain past medical records for this patient

Question 13

Which of the following patient problems is given the highest priority by the nurse using Maslow's hierarchy of needs?

A) Anxiety related to fear of the hospital
B) Ineffective airway clearance related to retained secretions
C) Fluid volume excess related to third spacing of fluid (edema)
D) Ineffective thermoregulation related to fever

Question 14

What does the process of analysis of patient data directly result in?

A) Validating actual problems or diagnoses
B) Determining the nursing interventions of importance
C) Identifying actual or potential problems amenable to nursing intervention
D) Confirming the medical diagnosis

Question 15

Which of the following is considered subjective data in information gathering from the patient?

A) Pulse and blood pressure measurements
B) ECG pattern
C) Diaphoresis
D) Pain

Question 16

Which of the following is a correctly stated nursing diagnosis?

A) Fluid volume deficit
B) Hypovolemia related to vomiting
C) Fluid volume deficit related to vomiting as evidenced by increased heart rate and decreased urine output
D) Hypovolemia related to nausea as evidenced by restlessness and anxiety

Question 17

Critical thinking in nursing needs to include which of the following important variables?

A) Consideration of ethics and responsible decision making
B) Ability to act quickly, often on impulse
C) Ability to determine the best nursing interventions regardless of patient's values and beliefs
D) Flexible thinking that rarely follows a pattern or considers standards

Question 18

Which of the following describes the primary difference between nursing diagnoses and medical diagnoses?

A) Nursing diagnoses identify simple instead of complex problems.
B) Nursing diagnoses must be verified by a physician.
C) Nursing diagnoses, like medical diagnoses, identify medical diseases.
D) Nursing diagnoses identify problems that can be treated with independent nursing actions.

Question 19

A patient is admitted with asthma.The nurse's assessment finds a temperature of 99° F,wheezing,speaking in three-word phrases,and respiratory rate of 16 breaths per minute.Which of the following are the best defining characteristics to support the diagnosis of ineffective airway clearance related to inflammation and constriction of the bronchial tree?

A) Elevated temperature and respiratory rate
B) Diagnosis of asthma with wheezing
C) Wheezing and speaking in three-word phrases
D) Limited vocalization and fever

Question 20

Which of the following statements has all of the necessary criteria for a well-written outcome?

A) Patient will consume 50% of meals with no nausea and vomiting by 24 hours postsurgery.
B) Therapist will report improvement in patient's range of motion on a daily basis.
C) Patient will ambulate in the halls a little today.
D) Patient's condition will improve before discharge.

Question 21

Which of the following is an appropriate long-term goal to measure diabetes control for a patient in whom diabetes has been newly diagnosed?

A) Patient will inject insulin twice daily.
B) Patient will keep appointments with physician over the next 6 months.
C) Patient's A1c will be 5% at 1 year postdiagnosis.
D) Patient's recorded blood glucose will be between 60 and 120 mg/dL each day.

Question 22

The nurse is admitting a patient for surgery.The patient is twisting a handkerchief over and over while saying,"I"m going to have a little mole removed.I'm not worried.The surgery will take only an hour,and then I will go home.I've never been sick a day in my life,so I"ll be fine." The nurse finds the following during her physical assessment: blood pressure is 150/90; temperature is 98.6° F; pulse is 88 beats per minute; respiration is 20 breaths per minute; black,brown,and red pigmented pea-sized raised area on her shoulder.Which of the above information would be considered objective data?

A) Twisting handkerchief
B) Blood pressure 150/90
C) "I'm having this little mole removed."
D) Patient is worried.
E) Patient is exhibiting denial.

Question 23

The use of standardized plans of care for different patient populations has

A) facilitated the use of critical paths as interdisciplinary plans of care.
B) required the nurse to individualize the plan of care to the patient.
C) eliminated the need for the nurse to develop a plan of care for an individual.
D) increased the time the nurse has to document the plan of care.

Question 24

Which of the following represents an interdependent nursing action?

A) Giving the patient an ordered medication
B) Bathing the patient
C) Inserting a Foley catheter
D) Participating in a "code" (cardiac arrest response)

Question 25

The nurse is admitting a patient for surgery.The patient is twisting a handkerchief over and over while saying,"I'm going to have a little mole removed.I'm not worried.The surgery will take only an hour,and then I will go home.I've never been sick a day in my life,so I'll be fine." The nurse finds the following during her physical assessment: blood pressure is 150/90; temperature is 98.6° F; pulse is 88 beats per minute; respiration is 20 breaths per minute; black,brown,and red pigmented pea-sized raised area on her shoulder.Which of the above information would be considered subjective data?

A) Pigmented mole on shoulder
B) "I'm not worried… I'll be fine."
C) Patient is anxious.
D) Heart rate is increased.
E) "The surgery will take only an hour and then I will go home."

Question 26

A patient is in respiratory distress and placed on oxygen.Which is the most appropriate short-term goal?

A) Nasal cannula remains in place.
B) Patient completes morning care and eats breakfast.
C) Patient verbalizes that he is breathing better after lunch.
D) Patient maintains an oxygen saturation of 90% during the shift.

Question 27

A nurse reviewing a patient's care plan notes a goal of "Patient will ambulate 50 feet,three times in the hallway today." According to Bloom,what taxonomic category is this goal?

A) Affective domain
B) Physical domain
C) Psychomotor domain
D) Cognitive domain

Question 28

Developing sound clinical judgment is a professional responsibility of the nurse.Which statements indicate behaviors that improve clinical judgment?

A) "I always assess before acting and make changes as needed."
B) "I only work the shifts I am assigned and usually refuse to float to other units."
C) "I look for research findings to support my nursing actions."
D) "I believe that every patient deserves my very best efforts."
E) "I have read the professional nursing standards."

Question 29

The nurse instructs the patient about incentive spirometry as preoperative teaching.Which phase of the nursing process does this illustrate?

A) Assessment
B) Planning
C) Implementation
D) Evaluation

Question 30

A "well-cultivated critical thinker" is an individual who does which of the following?

A) Raises questions
B) Recognizes alternative ways to see problems
C) Uses only logic to determine relevance of information
D) Implements solutions to complex problems only as an individual
E) Criticizes solutions and alternatives suggested by others

Question 31

Which of the following is an independent nursing intervention?

A) Teaching a patient with congestive heart failure to weigh herself daily
B) Recommending an extra dose of diuretic to the patient whose weight has increased 2 pounds overnight
C) Changing the first surgical dressing on a patient after surgery
D) Transferring a patient out of the intensive care unit 2 days after vascular surgery

Question 32

Several methods have been developed to assist nurses in organizing patient data.They include

A) Henderson's 14 nursing problems.
B) Gordon's 11 functional health patterns.
C) Nightingale's ecological framework.
D) Abdellah's 21 nursing problems.

Question 33

In the nursing process,the evaluation phase is used to determine the

A) value of the nursing intervention.
B) accuracy of problem identification.
C) the quality of the plan of care.
D) degree of outcome achievement.