Deck 2: Critical Thinking and the Nursing Process

Question 1

During an intake interview,the nurse observes the patient grimacing and holding his hand over his stomach.The patient previously denied having any pain.What action should the nurse take next?

A) Examine the history closely for etiology of pain.
B) Ask the patient if he is experiencing abdominal pain.
C) Record that patient seems to be having abdominal discomfort.
D) Physically examine the patient's abdomen.

Answer 1

Ask the patient if he is experiencing abdominal pain.

Question 2

The nurse is completing the medication reconciliation form for a patient.Which information is most important for the nurse to include?

A) The patient reports taking Ginkgo biloba daily for the last 6 months.
B) The patient reports having high hematocrit levels during his last hospital stay.
C) The patient reports he has been diabetic for 10 years.
D) The patient reports having a recent infection.

Answer 2

The patient reports taking Ginkgo biloba daily for the last 6 months.

Question 3

Which technique should the nurse employ to best assess skin turgor?

A) Examine mucous membranes of the mouth.
B) Compare limbs for similar color.
C) Pinch a skinfold on chest to assess for tenting.
D) Palpate the ankles for evidence of pitting edema.

Answer 3

Pinch a skinfold on chest to assess for tenting.

Question 4

During a morning assessment,the nurse observes that the patient displays significant edema of both feet and ankles.Which statement best documents these findings?

A) Pitting edema present in both feet and ankles
B) Edema in both feet and ankles approximately 4 mm deep
C) 4 mm pitting edema quickly resolving
D) Bilateral pitting edema in feet and ankles, 4 mm deep, resolving in 3 seconds

Question 5

The nurse is caring for a newly admitted patient who is describing his recent symptoms to the nurse.This scenario is an example of which type of source?

A) Primary
B) Objective
C) Secondary
D) Complete

Question 6

The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility.Which goal/outcome statement best correlates with this diagnosis?

A) The patient will sit in chair at bedside for 15 minutes after each meal.
B) The nurse will assist the patient to chair every shift.
C) The nurse will assess skin and record condition every shift.
D) The patient will change positions frequently.

Question 7

Which foundational behavior is necessary for effective critical thinking?

A) Unshakable beliefs and values
B) An open attitude
C) An ability to disregard evidence inconsistent with set goals
D) An ability to recognize the perfect solution

Question 8

The nurse is explaining the components of a complete problem statement/nursing diagnosis.In addition to the NANDA stem and etiology,which other component should the diagnosis include?

A) A time reference for meeting the need
B) A designation of what the patient should do
C) Signs and symptoms of the problem assessed
D) A specifically worded medical diagnosis

Question 9

The nurse is performing an intake interview on a new resident to the long-term care facility.The nurse detects the odor of acetone from the patient's breath.Which term accurately describes this assessment?

A) Inspection
B) Observation
C) Auscultation
D) Olfaction

Question 10

The nurse is caring for a patient with a goal/outcome statement of Patient will sleep for 5 hours uninterrupted each night.Which nursing intervention should the nurse include?

A) Medicate with sedative each night.
B) Offer warm fluids frequently.
C) Arrange for a large meal at supper.
D) Discourage daytime napping.

Question 11

The nurse who has recently moved from Louisiana to Texas is uncertain about the LPN/LVN's role in applying the nursing process.Which source is most appropriate source for the nurse to consult?

A) Hospital policies
B) The Texas State Board of Nursing
C) Rules and regulations of the Louisiana Nurse Practice Act
D) The National Association of Practical Nurse Education and Service

Question 12

The nurse adds a nursing order to the care plan related to a patient with a problem statement/nursing diagnosis of altered nutrition/Nutrition: Less Than Body Requirements Related to Nausea and Vomiting.Which nursing order should the nurse include in the plan of care?

A) Medicate with an antiemetic before each meal.
B) Offer crackers and iced drink before each meal.
C) Change diet to clear liquids.
D) Give nothing by mouth until nausea subsides.

Question 13

Which fundamental belief underscores the basis of the nursing process?

A) Recognition that basic needs must be met by the individual without assistance.
B) Acknowledgment that patients and families appreciate an efficient health care system that functions without their input.
C) A focus on disease control as the most important aspect of patient care.
D) Recognition that all people have worth and dignity.

Question 14

The nursing team is prioritizing the problem statement/nursing diagnoses of an overweight hospital patient.Which problem statement/nursing diagnosis would be most important for this patient?

A) Risk for dehydration related to vomiting.
B) Activity intolerance related to shortness of breath.
C) Knowledge deficit related to weight reduction diet.
D) Altered self-image related to excessive weight.

Question 15

After evaluating the nursing care plan,the nurse finds lack of progress toward the goal.What action should the nurse take next?

A) Create a more accessible goal.
B) Revise the nursing interventions.
C) Change the problem statement/nursing diagnosis.
D) Use a new evaluation plan.

Question 16

Which example shows that the nursing student demonstrates compliance with the Health Insurance Portability and Accountability Act (HIPAA)?

A) The student uses the patient's full name only on clinical assignments submitted to the instructor.
B) The student uses the facility printer to copy laboratory reports on an assigned patient.
C) The student shreds any documents that contain identifying patient information before leaving the clinical facility.
D) The student asks the patient for permission to copy laboratory and diagnostic reports for educational purposes.

Question 17

The diabetic patient who had blood drawn for an HbA₁c level says,"I don't know why they want to look at my hemoglobin." Which response is most appropriate for the nurse to make?

A) "Diabetes increases your risk of bleeding."
B) "The HbA₁c provides information relative to blood sugar levels for the last 2 to 3 months."
C) "Hemoglobin levels and blood sugar levels are closely related."
D) "The HbA₁c tells if you have type 1 or type 2 diabetes."

Question 18

Which statement explains the reason for inclusion of potential problems in the nursing care plan?

A) To alert nursing staff to prevent potential complications.
B) To remind the family of potential problems.
C) To broaden the assessment of the caregiver.
D) To educate the patient to aspects of her health.

Question 19

While conducting an admission interview,the nurse questions the patient about pain.The patient responds,"No.I'm pretty wobbly." Which action should the nurse take next?

A) Repeat the question about pain.
B) Ask the patient to clarify his meaning.
C) Record that the patient denied pain.
D) Record that the patient stated he was wobbly.

Question 20

The nurse is assessing a new patient who complains of his chest feeling tight.The patient displays a temperature of 100° F and an oxygen saturation of 89%,and expectorates frothy mucus.Which finding is an example of subjective data?

A) Temperature
B) Oxygen saturation
C) Frothy mucus
D) Chest tightness

Question 21

The nurse explains to the nursing student that the application of critical thinking to patient care involves which factor(s)?

A) Identification of a patient problem
B) Setting priorities
C) Concentrating on the patient rather than family needs
D) Use of logic and intuition
E) Expansion of thought beyond the obvious

Question 22

The nurse is caring for a patient with pneumonia who complains of shortness of breath.Further assessment reveals an oxygen saturation of 89% on room air,28 respirations/min with bilateral crackles in lung bases,blood pressure of 160/94,and a pulse rate of 102 beats/min.Which nursing diagnosis is priority for this patient?

A) Activity Intolerance
B) Impaired Gas Exchange
C) Ineffective Cardiopulmonary Tissue Perfusion
D) Self-Care Deficit: Bathing and Hygiene

Question 23

Which statement(s)demonstrates application of the nursing process?

A) Performing a head-to-toe assessment.
B) Updating the patient care plan on a weekly basis.
C) Evaluating if patient goals have been met.
D) Determining if nursing interventions need to be changed based on lack of patient progress toward meeting goals.
E) Ensuring that all personnel caring for the patient are implementing the care plan and working toward the same goal.

Question 24

Place the steps of the nursing process in their proper sequence.

Step 4

A)Evaluation
B)Assessment
C)Implementation
D)Planning
E)Problem statement/nursing diagnosis

Question 25

The nursing student demonstrates knowledge of the proper use of the ___________ when determining that it is safe to administer meperidine (Demerol)and promethazine (Phenergan)together.

Question 26

Which example(s)demonstrate patient care that reflects knowledge of the National Patient Safety Goals?

A) Identifying the patient prior to medication administration by asking the patient to state his or her name.
B) Reporting any sentinel event to the facility's quality assurance team.
C) Assessing the patient's heartrate prior to administration of digoxin.
D) Performing hand hygiene prior to performing a patient assessment.
E) Documenting the appropriate time of medication administration.

Question 27

The LPN/LVN adheres to facility policy regarding core measures by performing which interventions during patient care?

A) Administering the ordered amount of insulin to a patient with type 1 diabetes.
B) Performing a thorough patient assessment upon admission to the health care facility.
C) Documenting accurately and at appropriate intervals in the patient's record.
D) Providing patient teaching regarding proper diet for the patient diagnosed with renal failure.

Question 28

Shortness of breath due to emphysema would be a major component of the _________ care plan.

Question 29

Place the steps of the nursing process in their proper sequence.

Step 1

A)Evaluation
B)Assessment
C)Implementation
D)Planning
E)Problem statement/nursing diagnosis

Question 30

Place the steps of the nursing process in their proper sequence.

Step 3

A)Evaluation
B)Assessment
C)Implementation
D)Planning
E)Problem statement/nursing diagnosis

Question 31

Place the steps of the nursing process in their proper sequence.

Step 5

A)Evaluation
B)Assessment
C)Implementation
D)Planning
E)Problem statement/nursing diagnosis

Question 32

Place the steps of the nursing process in their proper sequence.

Step 2

A)Evaluation
B)Assessment
C)Implementation
D)Planning
E)Problem statement/nursing diagnosis