5 concepts of critical thinking ANS✔✔ Standards Attitudes Competencies
Experience Specific Knowledge Base
Nursing Process ANS✔✔ The nursing process is a variation of scientific
reasoning that involves five steps: assessment, nursing diagnosis, planning,
implementation, and evaluation.Assess (collection verification of data and
analysis of data) Diagnose, Plan, Implement, Evaluate
,cue ANS✔✔ obtain information that you obtain through sense. (Lies still with
arms along side: tense. States has not turned in some time. Reports pain a 7
and on scale of 0-10)
Sources of Data ANS✔✔ Patient, family and significant other, health care
team, medical records, other records and scientific literature
An initial patient-centered interview involves ANS✔✔ (1) setting the stage,
(2) gathering information about the patient's problems and setting an
agenda, (3) collecting the assessment or a nursing health history, and (4)
terminating the interview.
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's
been over 6 months since you've been here, but your appointment was for
every 2 months. Tell me about that. Also I see from your last visit that the
doctor recommended routine exercise. Can you tell me how successful
you've been in following his plan?" The nurse's assessment covers which of
Gordon's functional health patterns? ANS✔✔ Health perception-health
management pattern
The nurse observes a patient walking down the hall with a shuffling gait.
When the patient returns to bed, the nurse checks the strength in both of the
patient's legs. The nurse applies the information gained to suspect that the
patient has a mobility problem. This conclusion is an example of: ANS✔✔
Clinical inference.
A 72-year-old male patient comes to the health clinic for an annual follow-up.
The nurse enters the patient's room and notices him to be diaphoretic,
holding his chest and breathing with difficulty. The nurse immediately checks
the patient's heart rate and blood pressure and asks him, "Tell me where
your pain is." Which of the following assessment approaches does this
scenario describe? ANS✔✔ A problem-oriented approach
, The nurse asks a patient, "Describe for me a typical night's sleep. What do
you do to fall asleep? Do you have difficulty falling or staying asleep? This
series of questions would likely occur during which phase of a patient-
centered interview? ANS✔✔ Working phase
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300
lbs), has diabetes, and works part time in the kitchen of a restaurant. The
patient is facing surgery for gallbladder disease. Which of the following
approaches demonstrates the nurse's cultural competence in assessing the
patient's health care problems? ANS✔✔ "You have four children; do you
have any concerns about going home and caring for them?"
A nurse is checking a patient's intravenous line and, while doing so, notices
how the patient bathes himself and then sits on the side of the bed
independently to put on a new gown. This observation is an example of
assessing: ANS✔✔ Patient's level of function.
A patient who visits the surgery clinic 4 weeks after a traumatic amputation
of his right leg tells the nurse practitioner that he is worried about his ability
to continue to support his family. He tells the nurse he feels that he has let
his family down after having an auto accident that led to the loss of his left
leg. The nurse listens and then asks the patient, "How do you see yourself
now?" On the basis of Gordon's functional health patterns, which pattern
does the nurse assess ANS✔✔ Self-perception-self-concept pattern
During a visit to the clinic, a patient tells the nurse that he has been having
headaches on and off for a week. The headaches sometimes make him feel
nauseated. Which of the following responses by the nurse is an example of
probing? ANS✔✔ Tell me what makes your headaches begin.
Steps of NOTICING ANS✔✔ Identifying Assumptions
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