1.  Module 1 Critical Thinking & The Nursing Process A Closer Look at Each Step of the Nursing Process

2. WHAT TOPICS WERE CLEAR? Ch 2 – Critical Thinking & Nursing Process

3. WHAT TOPICS WERE CLOUDY? Ch 2 – Critical Thinking & Nursing Process

4. The most correct definition of “critical thinking” is 1. A problem-solving process that enable’s one to show others they are wrong 2. An examination of one’s own beliefs in order to defend them intelligently 3. Purposeful, analytical thinking that results in a reasoned decision 4. Rational thinking that results in obtaining the one correct answer

5. Correct answer: 3 Most definitions of critical thinking include the concept of it being “purposeful” and deliberate. It is more than just problem solving and is not used exclusively to defend one’s beliefs. Critical thinking enables a person to see that there may be more than one correct answer.

6. College courses such as Microbiology and Human Growth & Development present content that is considered part of theoretical nursing knowledge. 1. TRUE 2. FALSE

7. Correct answer: 1 Knowledge gained in these courses helps the nurse develop a more holistic and complete plan of patient care.

8. The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered a/an 1. Focused assessment 2. Initial assessment 3. Ongoing assessment 4. Special needs assessment

9. Correct answer: 3 This type of assessment can be completed at any time after the initial assessment. Gathering data at the beginning of a shift will enable the nurse to more effectively evaluate how to proceed with the plan of care for the shift.

10. Which action by the nurse might be a barrier to obtaining complete and reliable information from an interview with the client? 1. Noting that the client’s body language indicates that he or she is fatigued 2. Maintaining eye contact with the client if it is not culturally inappropriate to do so 3. Carefully guiding the conversation so that important topics are discussed 4. Asking the client directly, “Why are you not taking your insulin?”

11. Correct answer: 4 During the client interview avoid asking “why” questions. Not only do they suggest disapproval, but also many clients do not know “why” they do or do not comply with therapy.

12. When gathering admission assessment data the nurse obtains a weight of 200 pounds. The client states, “I’ve never weighed that much!” The nurse should 1. Explain to the client how weight gain occurs 2. Check the calibration and re-weigh the client 3. Document the weight as 200 pounds 4. Instruct the UAP to re- weigh the client in 2 hours

13. Correct answer: 2 It is important to FIRST validate data when there is a mismatch between what the client states as history and the data obtained. Validating data often includes ensuring that equipment is functioning properly first.

14. The client’s activity level has decreased post-hip replacement surgery. She has been receiving opioid analgesia and has decreased fluid intake. The nurse chooses: 1. A risk nursing diagnosis 2. A collaborative diagnosis 3. An actual nursing diagnosis 4. A possible nursing diagnosis

15. Correct answer: 1 The data (cues, defining characteristics) suggest that the client is at risk for constipation.

16. Identify the priority nursing diagnosis 1. Impaired verbal communication related to altered central nervous system 2. Fluid volume excess related to compromised regulatory mechanism 3. Impaired physical mobility related to discomfort 4. Activity intolerance related to generalized weakness

17. Correct answer: 2 Maslow’s hierarchy of human needs places survival needs as a priority. Fluid volume excess can lead to pulmonary edema, impaired gas exchange, and respiratory failure. Fluid volume excess is therefore life-threatening and would be a high priority when ranking problems according to problem urgency.

18. The client has reddened skin and an open abrasion on his elbow from prolonged bed rest. In the examining the components of the nursing diagnosis “Impaired Skin Integrity”, the reddened skin and open abrasion would be 1. The related factors 2. The risk factors 3. The defining characteristics 4. The diagnostic label

19. Correct answer: 3 Defining characteristics are the signs and symptoms that allow the nurse to identify a client problem (also called cues).

20. Worksheet #1 – Steps of the Nursing Process  REMEMBER ADPIE  A ssessment  D iagnosis  P lanning Outcomes  P lanning Interventions  I mplementation  E valuation

21. Worksheet #2 Nursing Diagnosis Question 1-4  Remember the parts of the diagnostic statement:  Problem/Label  Etiology/Cause  Defining Characteristic/Signs & Symptoms  Format for writing the diagnostic statement:  Problem R/T Etiology AMB Defining Characteristics Nausea R/T chemotherapy AMB reports being “sick to stomach” **Risk factors – list in place of etiology when patient is at risk for a problem, but the problem does not currently exist (Risk for Deficient Fluid Volume R/T excessive vomiting/diarrhea

22. How to Use a Nursing Dx Resource to Select Nursing Diagnoses  Start with the Assessment Data  Select a nursing diagnosis that “makes sense” to you (use NANDA list)  Look up the Definition of the selected nursing diagnosis and validate it appropriateness for your patient (search from “2009-2011 NANDA-I Nursing Diagnoses” section in Ackley  Read the Defining Characteristics for the selected nursing diagnosis and validate the appropriateness for your patient  Identify the etiology/cause of the problem – the “Related Factors r/t” listed in the handbook or in your own words based on assessment data/history of illness  Identify the the defining characteristics or signs/symptoms your patients has (the AMB part of the nursing diagnosis statement)

23. How to Use a Nursing Dx Resource to Select Nursing Diagnoses  Start with the Medical Diagnosis / Problem  Search the Medical Diagnosis or Problem in Ackley  Select appropriated nursing diagnoses based on your patient’s assessment data  Modify nursing diagnosis statement, as needed, to individualize for your patient

24.  Worksheet #2 – Clustering Data to Select an Appropriate Diagnosis Question 5 For each of the following cue clusters (S/S-Hx) decide whether the cues represent a pattern; that is, are all the cues related in some way? If so, explain how they are related. If not, state which cue does not fit. If you do not have enough theoretical knowledge to know for sure, draw on your past experiences and discuss the clusters with other students. a.History of severe vomiting/diarrhea, confused, dry skin, abnormal return of skin turgor (more than 4 seconds), thirst, scanty/dark urine. Admitted with diagnosis of dehydration. b.Complains of severe discomfort and limited range of motion in knees, uses walker, medical diagnosis of osteoarthritis c.Has hard, painful bowel movement about every 3 days; does not exercise regularly; eats very little dietary fiber; dry skin

25. Care plans that focus on DRGs (the patient’s medical diagnostic category) and are organized on a timeline to meet recommended lengths of stay are called standardized nursing care plans. 1. TRUE 2. FALSE

26. Correct answer: 2 These types of care plans are called critical or clinical pathways.

27. Identify the long-term goal 1. Reach 92% oxygen saturation level on room air by tomorrow 2. Administer his own insulin using correct technique by discharge 3. Show presence of granulation tissue in wound bed in 30 days 4. Produce a urine output of 400 mL per 8 hour shift within 72 hours

28. Correct answer: 3 A long-term goal indicates that the resolution to a problem is expected to occur over weeks to months or more.

29. Identify which outcome/goal is written correctly 1. Produce adequate urine output by the end of the shift 2. Show evidence of resolution of pneumonia as evidenced by clear breath sounds bilaterally by discharge 3. Ambulate 20 feet in the hallway using his walker by evening shift tomorrow 4. Drink more fluids than he did yesterday by 7:00 pm today

30. Correct answer: 3 This statement meets all of the criteria for a correctly written client outcome. “Adequate” is not measurable; clear breath sounds only would not be evidence of the resolution of pneumonia and this is the medical diagnosis; “more fluids than yesterday” is vague and unclear.

31. It is a very busy day on the nursing unit. The RN asks the UAP to complete the following tasks. He delegates inappropriately when asking the UAP to 1. Make sure the client takes his pills after his meal 2. Ambulate the post-surgical client to the bathroom 3. Bathe the client who is listed as a fall risk 4. Feed the client with severe visual impairment

32. Correct Answer: 1 Medication administration is not within the scope of practice of the UAP.

33. The nurse has determined that the goal for a particular nursing diagnosis on the client’s plan of care has not been met. It will be most important for the nurse to 1. Report this finding to the physician 2. Note this finding in the client’s record 3. Revise the plan of care 4. Remove the nursing diagnosis from the plan

34. Correct answer: 3 It will be most important for the nurse to review all of the other steps of the nursing process to determine if errors were made that prevented the goal from being achieved.

35. Worksheet #3 Planning Outcomes & Interventions  Types of outcomes/goals  Short-Term Goal: few hours / days  Long-Term Goal: week, month or longer  Format for writing goals/outcomes:  Subject – it’s understood the patient is the subject of outcome statements; do not state it, just think it: the client/patient will  Action – what the patient will do  Performance criteria – how the patient will do it (measureable)  Target time – when the patient will do it  Example: Demonstrate self-administration of insulin, without prompting, by discharge USE YOUR NURSING DIAGNOSIS RESOURCE!

36. Worksheet #3 Planning Interventions  Format for writing nursing interventions:  Subject – it’s understood the nurse is the subject of interventions; do not state it, just think it: the nurse will  Action – what the nurse will do  Times and limits – when and within what parameters the nurse will do it  Example: Monitor all laboratory results – serum albumin, total serum protein, hemoglobin & hematocrit – each week to evaluate nutritional status USE YOUR NURSING DIAGNOSIS RESOURCE!

37. Implementation Phase  This phases includes doing, delegating & documenting  Includes what the nurse does & what the nurse delegates  The nurse delegates as follows:  RIGHT TASK  RIGHT CIRCUMSTANCE  RIGHT PERSON  RIGHT DIRECTION/COMMUNICATION  RIGHT SUPERVISION  The final step of the implementation phase is documentation - recording of the nursing interventions & the patient’s response

38. Evaluation Phase  Evaluate  Client’s progress toward goals  Effectiveness of nursing care plan  Quality of care in the health-care setting  Relate outcome to interventions  Draw conclusions about problem status  Revise the care plan, as needed

39. Evaluation Phase  Sample Evaluation Statement – Active Problem  Nursing Dx : Activity intolerance R/T prolonged bed rest, exertional dyspnea AMB verbalization of overwhelming lack of energy, abnormal heart rate with activity  Goal/Outcome : Demonstrate increased tolerance to activity by walking 15 feet without becoming short of breath  Evaluation Statement : - Goal Met: Ambulates 15 feet without becoming short of breath - Goal Not Met: Unable to ambulate 15 feet without becoming short of breath

40. Evaluation Phase  Sample Evaluation Statement – Potential (Risk) Problem  Nursing Dx : Risk for impaired skin integrity R/T immobilization  Goal/Outcome : Skin will remain intact throughout hospitalization.  Evaluation Statement : - Goal Met: Skin remains intact during hospitalization - Goal Not Met: 2cm area of skin breakdown to coccyx A potential problem becomes an ACTIVE PROBLEM patient develops signs/symptoms of the problem: Impaired skin integrity R/T immobilization AMB 2cm area of skin breakdown to coccyx