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Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 15: Critical Thinking in Nursing Practice MULTIPLE CHOICE 1. Which of the following best reflects the philosophy of critical thinking as taught by a nurse educator to a nursing student? 1. “Think about several interventions that you could use with this client.” 2. “Don’t draw subjective inferences about your client—be more objective.” 3. “Please think harder—there is a single solution for which I am looking.” 4. “Trust your feelings—don’t be concerned about trying to find a rationale to your decision.” ANS: 1 The nurse educator is asking the student to synthesize critical thinking skills by encouraging the student to examine alternatives to meet the client’s unique needs within the context of the nursing process. Drawing inferences is a specific critical thinking competency used in diagnostic reasoning. The educator who tells the student not to draw inferences is not allowing the student to practice competencies necessary for specific critical thinking in clinical situations. The critical thinker will look beyond a single solution to a problem. Intuition develops as one’s clinical experience increases. The nursing student should examine rationales in order to make good decisions. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 2. The second component of critical thinking in the “critical thinking model” is: 1. Experience 2. Competencies 3. Specific knowledge 4. Diagnostic reasoning ANS: 1 Experience is the second component of critical thinking in the “critical thinking model.” The third component of the “critical thinking model” is competencies. Specific knowledge base is the first component of the “critical thinking model.” Diagnostic reasoning is a specific critical thinking competency in clinical situations. DIF: A REF: 222 OBJ: Knowledge TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment
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3. The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is “not right” with the client and proceeds to take the vital signs. This is the nurse acting on: 1. Intuition 2. Reflection 3. Knowledge 4. Scientific methodology ANS: 1 Intuition is an inner sensing that something is so, as in this example. Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or ing that a set of facts agrees with reality. DIF: A OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 4. The nurse manager has developed a staff protocol for peer evaluation. The nurses on her surgical unit are nervous ing her instrument. If the nurse manager continues to implement the new strategy, which of the following critical thinking attitudes is she portraying? 1. Humility 2. Risk-taking 3. ability 4. Independent thinking ANS: 2 This is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in trying different approaches to solving problems. Humility is a critical thinking attitude in which a person its what they do not know and tries to acquire the knowledge needed to make proper decisions. To be able means to be answerable for the outcomes of your actions. To think independently, one questions others’ ways of interpreting knowledge and looks for rational and logical answers to problems. DIF: A REF: 224 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 5. The nurse is working with a client who has recently had a colostomy and is having difficulty using the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of: 1. Inference 2. Management
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3. Problem-solving 4. Diagnostic reasoning ANS: 3 This is an example of the critical thinking strategy of problem-solving. The nurse gathers information from the client and combines that information with what the nurse already knows about ostomy care to find a solution. Effective problem-solving involves the examination of alternatives. Inference is the process of drawing conclusions. Management is not a critical thinking strategy. Diagnostic reasoning is a process of determining a client’s health status after the nurse assigns meaning to the behaviors, physical signs, and symptoms presented by the client. DIF: A REF: 219 OBJ: Comprehension TOP: Nursing Process: Assessment/Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 6. Which of the following is an example of a nurse’s statement that reflects using the scientific method in the nursing process? 1. “I believe that this client is getting depressed.” 2. “The client doesn’t look right to me; I think something is wrong.” 3. “The client’s husband told me that she is feeling very uncomfortable.” 4. “The client reports more pain than yesterday and her blood pressure is elevated.” ANS: 4 Reporting more pain than yesterday and elevated blood pressure reflects using the scientific method in the nursing process. The nurse identified a problem of pain, hypothesized that it was greater than the day before, and collected data to evaluate its reality. Believing the client is depressed or thinking something is wrong reflect intuition. Speaking with the husband reflects information gathering, which may be used in diagnostic reasoning. DIF: A REF: 218 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 7. The nurse decides to ister tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address? 1. Assessment 2. Nursing diagnosis 3. Planning 4. Implementation ANS: 4
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Taking appropriate action demonstrates the implementation step of the nursing process. Assessment involves the gathering of data. When formulating a nursing diagnosis, the nurse critically examines and analyzes the data, and identifies the client’s response to a problem. The nurse may then determine priorities. Planning involves establishing goals and expected outcomes of care. DIF: A REF: 221 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 8. The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who: 1. Has a documented blood pressure of 90/50 2. Was medicated for back pain 10 minutes ago 3. Has an order to be out of bed and ambulated 4. Requires instructions for wound care before discharge ANS: 1 The nurse prioritizes actions and determines to see this client first because of a lower than normal blood pressure for a postoperative patient. This nurse is using scientifically and practice-based criteria for making clinical judgment. This is an example of following standards. The nurse uses criteria such as the clinical condition of the client, Maslow’s hierarchy of needs, and risks involved in treatment delays to determine which clients have the greatest priority for care. In answers 2 through 4, the client is not reported to be having any problems and therefore is not the priority. DIF: C REF: 221 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment/Coordination/Setting Priorities 9. There are a variety of levels of critical thinking. An example of critical thinking at the complex level is: 1. Giving medication at the time ordered 2. Following a procedure for catheterization step-by-step 3. Reviewing all clients’ medical records thoroughly 4. Discussing various alternative pain management techniques ANS: 4 Discussing alternative pain management techniques is an example of critical thinking at the complex level. The nurse analyzes and examines alternatives more independently. Giving medication at the time ordered is an example of the basic level of critical thinking. Following a procedure step-by-step is an example of the basic level of critical thinking. Reviewing the client’s medical records thoroughly is an example of gathering data and may be used in evaluation of a client’s care.
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DIF: C REF: 218 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 10. The nurse is deciding on the type of dressing to use for a client. Which step of the decision-making process is being used when the nurse observes the absorbency of different dressing brands? 1. Defining the problem 2. Making final decisions 3. Testing possible options 4. Considering consequences ANS: 3 The nurse who observes the absorbency of different brands of dressing is demonstrating testing of possible options. This is not an example of defining the problem. The nurse has not yet made a final decision. The nurse is not examining pros and cons, and therefore is not considering consequences. DIF: A REF: 219 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 11. Which one of the following examples demonstrates the critical thinking attitude of responsibility and authority? 1. Reporting client difficulties 2. Offering an alternative approach 3. Looking for a different treatment option 4. Sharing ideas about nursing interventions ANS: 1 Reporting client difficulties demonstrates the critical thinking attitude of responsibility and authority. Asking for help if uncertain and following standards of practice also demonstrate the critical thinking attitudes of responsibility and authority. Offering an alternative approach would demonstrate the critical thinking attitude of risk-taking. Looking for a different treatment option demonstrates the critical thinking attitude of creativity. Sharing ideas about nursing interventions demonstrates the critical thinking attitude of thinking independently. DIF: A REF: 223 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 12. Use of the intellectual standard of critical thinking implies that the nurse: 1. Questions the physician’s order 2. Recognizes conflicts of interest 3. Listens to both sides of the story
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4. Approaches assessment logically ANS: 4 Use of the intellectual standard of critical thinking implies that the nurse approaches assessment logically and consistently. Questioning the physician’s order is an example of the critical thinking attitude of risk-taking. Recognizing conflicts of interest demonstrates the critical thinking attitude of integrity. Listening to both sides of the story demonstrates the critical thinking attitude of fairness. DIF: A REF: 225 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 13. A client requires urinary catheterization but has difficulty keeping her legs in the usual position needed for this procedure. The nurse has worked for many years and adapts the procedure to allow the client to lie on her side. This action is based on the critical thinking element of: 1. Curiosity 2. Experience 3. Perseverance 4. Scientific knowledge ANS: 2 Having worked for many years and being able to adapt a procedure to meet the client’s needs is an example of the second component of the critical thinking model—experience. Curiosity is a critical thinking attitude where the nurse asks why, and continues to learn more about the client to make appropriate clinical judgments. Perseverance is a critical thinking attitude where the nurse does not readily accept the easy answer but does look further to find necessary information and appropriate solutions. Scientific knowledge is knowledge acquired from the study of science. It may be acquired through education, such as coursework, or by reading nursing literature to remain current in nursing science. DIF: A REF: 222 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 14. Which of the following statements made by a nursing student concerning the use of critical thinking and client care requires follow-up by the nursing instructor? 1. “I feel it’s good practice to always have alternative interventions in mind.” 2. “I trust my feelings about a client’s needs since I work hard at knowing my client.” 3. “I always try to keep an open mind about what interventions my client will require.” 4. “I will wait until my assessment is completed before determining the client’s needs.” ANS: 2
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
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Intuition develops as one’s clinical experience increases. The nursing instructor should instruct the student to examine rationales in order to make good decisions regarding client needs. The instructor would encourage the student to examine alternatives to meet the client’s unique needs, so this statement would not require follow-up. Basing client care on identified client needs is the appropriate use of critical thinking, and so would not require follow-up. Basing client care on client needs identified by thorough nursing assessments is the appropriate use of critical thinking, and so would not require followup. DIF: C OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 15. Which of the following is the best example of a nurse’s use of reflection? 1. The nurse places a client experiencing respiratory difficulties in a high-Fowler’s position. 2. The nurse calls the provider when a client reports feeling “chilled and achy” while having an oral temperature of 100.2° F. 3. While caring for a client with a history of asthma, the nurse assesses the client’s pulse oximetry reading when he “doesn’t sound right.” 4. A nurse tells a client; “When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time.” ANS: 4 Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or ing that a set of facts agrees with reality. Intuition is an inner sensing that something is so, as in this example. DIF: C REF: 226 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 16. Which of the following nursing situations best reflects ability? 1. The nurse takes the oncology nursing certification examination. 2. The nurse files an incident report regarding a medication error. 3. The nurse assesses the client for the possible cause of his pain. 4. The nurse tells the client, “I don’t know but I will find out for you.” ANS: 2 To be able means to be answerable for the outcomes of your actions. Answer 2 is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in trying different approaches to solving problems. To think independently, one questions others’ ways of interpreting knowledge and looks for rational and logical answers to problems. Humility is a critical thinking attitude where a person its what they do not know and tries to acquire the knowledge needed to make proper decisions.
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DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 17. Which of the following nursing actions is the best example of problem solving? 1. Requesting the IV team to start an antibiotic drip on a client with a history of being a difficult stick 2. Offering to call the kitchen to provide an alternate breakfast for a client who does not like cooked cereal 3. Trying several difficult wound dressings to determine which one the client can apply the most effectively 4. Calling for another pain medication order when the current drug results in the client experiencing nausea ANS: 3 This is an example of the critical thinking strategy of problem solving. The nurse gathers information by using several different products and then uses this information to determine which will work best for the client. Effective problem solving involves the examination of alternatives. While requesting the IV team solves a problem, there is little critical thinking needed because it would be understood that the IV team would be called under these circumstances. Although calling the kitchen solves a problem, there is little critical thinking needed because it would be understood that the kitchen would be called under these circumstances. Calling for another pain medication order solves a problem, but there is little critical thinking needed because it would be understood that the provider would be called for a new drug order under these circumstances. DIF: C REF: 219 OBJ: Analysis TOP: Nursing Process: Assessment/Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 18. Which of the following clients should be prioritized with the most urgent need for a nursing assessment? 1. A new ission itted for swelling in the right ankle and knee 2. A second day postoperative client who received pain medication 30 minutes ago 3. A client who the nursing assistant found crying in the bathroom 4. A client ready for discharge who requires a final assessment and documentation ANS: 3 This client has an acute need that requires the nurse’s attention. The facility has a policy regarding the amount of time available in which to complete such an assessment and this client is in no acute distress, so the assessment does not have priority. While a pain assessment is required to evaluate the effectiveness of pain medication, it does not the have the priority of the other presented options. This client has no acute problems and so the assessment does not have the priority of some of the other options. DIF: C REF: 221 TOP: Nursing Process: Assessment
OBJ: Analysis
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MSC: NCLEX® test plan designation: Safe, Effective Care Environment 19. Which of the following nursing interventions is the best example of the implementation step of the nursing process? 1. Determining that the client’s ankle edema is worse after he ambulates 2. Asking the client to rate his ankle pain after receiving oral pain medication 3. Arranging for the client to receive pain medication 30 minutes before his ordered ambulation 4. Crushing the client’s pain medication to facilitate easier swallowing and thus minimize the risk of choking ANS: 4 Taking appropriate action demonstrates the implementation step of the nursing process. Assessment involves the gathering of data. Assessment involves the gathering of data. Planning involves establishing goals and expected outcomes of care. DIF: C REF: 221 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 20. Which of the following nursing actions best reflects the consequence stage of the decision-making process? 1. Being physically present when a client is given the results of a tissue biopsy 2. Witnessing the client sign consent for surgery forms before cardiac surgery 3. The client is informed of the various treatments available for his condition. 4. The nurse explains to the client the risks of leaving the hospital against medical advice. ANS: 4 The nurse is presenting the possible outcomes, and therefore is presenting consequences. Being physically present is not an example of defining the problem. Witnessing the client sign consent is an example of a final decision. In Answer 3 the client is being given various options. DIF: C REF: 219 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 21. The concept of nursing responsibility is best reflected in which of the following nursing actions? 1. Providing accurate and timely documentation regarding an incident resulting in a client fall 2. Suggesting that a client might prefer taking a particular medication at bedtime instead of in the morning 3. Posting a note on the unit Kardex how to best apply a dressing to a skin wound on a particular client 4. Referring to the institution’s policy manual when unsure of how to handle a client’s
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complaint regarding a social services consult ANS: 4 Asking for help if uncertain and following standards of practice best demonstrate the critical thinking attitudes of responsibility because failure to do so could result in client injury. Reporting client difficulties demonstrates the critical thinking attitude of responsibility but is not the best option of those available because it would not result in client injury/harm. Offering an alternative approach would best demonstrate the critical thinking attitude of risk-taking. Sharing ideas about nursing interventions best demonstrates the critical thinking attitude of thinking independently. DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 22. Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool? 1. Performing a head-to-toe assessment on a new ission 2. Placing a client experiencing shortness of breath on oxygen 3. Arbitrating a complaint between roommates over the television 4. Notifying a provider of a client’s allergy to an ordered medication ANS: 2 Use of the intellectual standard of critical thinking implies that the nurse approaches nursing care logically, consistently, and appropriately. This option reflects the use of such standards in a situation that addresses client distress. While performing a head-to-toe assessment is an example of intellectual standards, it is not the best example because it does not involve a client’s immediate distress. Listening to both sides of the story demonstrates the critical thinking attitude of fairness. Notifying a provider of a client’s allergy is an example of nursing responsibility. DIF: C REF: 225 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 23. The nurse is best demonstrating perseverance by: 1. Having a perfect attendance record 2. Completing a lengthy course on current chemotherapies 3. Repeatedly irrigating the nasogastric tube until it is patent 4. Sitting with a client until she is ready to discuss why she is crying ANS: 4
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Perseverance is a critical thinking attitude in which the nurse does not readily accept the easy answer but does look further to find necessary information and appropriate solutions. While perfect attendance shows a nurse’s willingness to complete the work responsibilities regardless of barriers, it is a better representation of responsibility. While completing a course on current chemotherapies shows the nurse’s willingness to pursue knowledge, it is more representative of the acquiring of scientific knowledge to remain current in nursing science. While repeatedly irrigating the nasogastric tube shows a willingness to repeat a procedure as often as is appropriate, it is a better representation of possessing knowledge of the procedure. DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 24. With regards to client care, the most likely reason that a veteran nurse tends to be a more skillful critical thinker than a new graduate nurse is because: 1. The veteran nurse has a varied history of client care experiences 2. Critical thinking improves with experience, longevity, and interest 3. Today’s short hospital stays minimize the opportunity to develop critical thinking skills 4. New graduates often lack the self-confidence to take the risks often required of critical decision making ANS: 2 Critical thinking is not a simple step-by-step, linear process that you learn overnight. It is a process acquired only through experience, commitment, and an active curiosity toward learning. While experience is a factor in the development of critical thinking skills, it is not the only factor. While having extended periods of time with clients has a positive effect on the development of critical thinking, it is not the primary or sole factor. While lack of self-confidence may have a negative effect on the development of critical thinking skills, it is not the primary or sole factor. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 25. The primary factor that distinguishes a professional nurse’s care from care provided by ancillary nursing staff is: 1. Critical thinking 2. Years of education 3. Professional licensure 4. Complexity of the task ANS: 1
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Clinical decision making separates professional nurses from technical personnel. While advanced education is a distinction, the primary factor regarding client care is the professional nurse is responsible for actions that require critical thinking decision making. Although licensure is a distinction, the primary factor regarding client care is the professional nurse is responsible for actions that require critical thinking decision making. 4. While complexity is a distinction, the primary factor regarding client care is that the professional nurse is responsible for actions that require critical thinking decision making. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 26. A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of the following represents the best response? 1. “A person with the educational background to solve problems.” 2. “A person who finds the problem and does what is best to fix it.” 3. “It’s someone who uses the scientific method to solve problems.” 4. “Someone who uses a system to work through and solve a problem.” ANS: 2 A critical thinker considers what is important in a situation, imagines and explores alternatives, considers ethical principles, and then makes informed decisions. Educational background may have an impact on critical thinking but it is not the primary or sole factor to consider. Although the scientific method is often used in critical thinking it is neither the only method nor the sole factor to consider. While an orderly method is used in critical thinking, it is not the only factor to consider. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 27. Which of the following statements made by a new graduate nurse regarding a client’s care needs requires follow-up by the mentor? 1. “No one really enjoys being hospitalized.” 2. “Every client is offered a back rub at bedtime.” 3. “All post surgery clients are reluctant to ambulate.” 4. “I always spend extra time with new clients to help them relax.” ANS: 3 Because no two clients respond exactly alike to similar health problems, you always have to observe each client closely in order to make critically sound decisions regarding that client’s needs. Answer 1 does not require follow-up because even if it is not true, it does not have an impact on the nurse’s perception of the client’s care needs. Answer 2 does not require follow-up because it is a nursing action that should be offered to all clients at bedtime.
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Answer 4 does not require follow-up because it is a nursing action that should be offered to all clients. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 28. A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care? 1. “I’m sure that friction and pressure have caused this problem.” 2. “Please be sure that her ankles are well padded when you place her in bed.” 3. “Do you have any suggestions on how we can minimize the pressure to her ankles?” 4. “It was an ineffective turning schedule that allowed this to happen so now we will reposition every hour.” ANS: 3 Nurses who apply critical thinking in their work focus on options for solving problems and making decisions, rather than quickly and carelessly forming quick solutions. Asking for staff input regarding interventions shows critical thinking. While Answer 1 may be true, it is knowledge or experience, not critical thinking, that brought about this conclusion. Although Answer 2 may represent an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion. While Answer 4 may be true and an example of an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 29. A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this client’s care needs? 1. “That surgery is painful. I’ll get her pain medication ready.” 2. “She was sleeping when I checked 15 minutes ago. I’ll go back in right now.” 3. “I’ll be responsible for her PM care so I can spend some uninterrupted time with her.” 4. “A mastectomy is a blow to a woman’s self image. I’ll notify her provider that she is depressed.” ANS: 2
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Analysis requires being opened-minded as you look at information about a client. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options? Although pain may be the cause of this client’s tears, there are other possible reasons, so making an assumption is not appropriate. Although Answer 3 shows the nurse’s intention to analyze the client’s needs, the delay is not appropriate. While the client may be experiencing some depression, there are other possible reasons for the tears and so the nurse should not assume. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 30. Which of the following statements made by a nurse regarding personal reflection related to client care requires follow-up by the unit’s nurse manager? 1. “Mary and I were comparing foot wound dressing techniques.” 2. “I’ve been caring for orthopedic clients for 10 years and I think I’ve seen it all.” 3. “I can’t believe that my client isn’t improving after 2 weeks of physical therapy.” 4. “I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4.” ANS: 4 Reflect on your experiences. Identify the ways you can improve your own performance. This option presents a rigid attitude concerning client pain needs. Answer 1 needs followup because it shows a willingness to explore other’s opinions. Answer 2 requires no follow-up because it does not reflect an inflexible attitude toward client care need. Answer 3 requires no follow-up because it does not reflect an inflexible attitude toward client care needs. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. The scope of a client’s health problem is a result of which of the following factors? (Select all that apply.) 1. Religious beliefs 2. Life experiences 3. Lifestyle choices 4. Work environment 5. Family relationships 6. Educational background ANS: 2, 3, 4, 5 Each client’s problems are unique and a product of many factors, including the client’s physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences. Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
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DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment
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3. The nurse enters the room of a client who has a history of heart disease. On looking at the client, the nurse feels that something is “not right” with the client and proceeds to take the vital signs. This is the nurse acting on: 1. Intuition 2. Reflection 3. Knowledge 4. Scientific methodology ANS: 1 Intuition is an inner sensing that something is so, as in this example. Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or ing that a set of facts agrees with reality. DIF: A OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 4. The nurse manager has developed a staff protocol for peer evaluation. The nurses on her surgical unit are nervous ing her instrument. If the nurse manager continues to implement the new strategy, which of the following critical thinking attitudes is she portraying? 1. Humility 2. Risk-taking 3. ability 4. Independent thinking ANS: 2 This is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in trying different approaches to solving problems. Humility is a critical thinking attitude in which a person its what they do not know and tries to acquire the knowledge needed to make proper decisions. To be able means to be answerable for the outcomes of your actions. To think independently, one questions others’ ways of interpreting knowledge and looks for rational and logical answers to problems. DIF: A REF: 224 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 5. The nurse is working with a client who has recently had a colostomy and is having difficulty using the provided supplies. The nurse works with the client to see which alternative supplies are easier for the client to use. This is an example of the critical thinking strategy of: 1. Inference 2. Management
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3. Problem-solving 4. Diagnostic reasoning ANS: 3 This is an example of the critical thinking strategy of problem-solving. The nurse gathers information from the client and combines that information with what the nurse already knows about ostomy care to find a solution. Effective problem-solving involves the examination of alternatives. Inference is the process of drawing conclusions. Management is not a critical thinking strategy. Diagnostic reasoning is a process of determining a client’s health status after the nurse assigns meaning to the behaviors, physical signs, and symptoms presented by the client. DIF: A REF: 219 OBJ: Comprehension TOP: Nursing Process: Assessment/Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 6. Which of the following is an example of a nurse’s statement that reflects using the scientific method in the nursing process? 1. “I believe that this client is getting depressed.” 2. “The client doesn’t look right to me; I think something is wrong.” 3. “The client’s husband told me that she is feeling very uncomfortable.” 4. “The client reports more pain than yesterday and her blood pressure is elevated.” ANS: 4 Reporting more pain than yesterday and elevated blood pressure reflects using the scientific method in the nursing process. The nurse identified a problem of pain, hypothesized that it was greater than the day before, and collected data to evaluate its reality. Believing the client is depressed or thinking something is wrong reflect intuition. Speaking with the husband reflects information gathering, which may be used in diagnostic reasoning. DIF: A REF: 218 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 7. The nurse decides to ister tablets of Tylenol instead of the intramuscular Demerol she has previously been providing her orthopedic client. Which step of the nursing process does this address? 1. Assessment 2. Nursing diagnosis 3. Planning 4. Implementation ANS: 4
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Taking appropriate action demonstrates the implementation step of the nursing process. Assessment involves the gathering of data. When formulating a nursing diagnosis, the nurse critically examines and analyzes the data, and identifies the client’s response to a problem. The nurse may then determine priorities. Planning involves establishing goals and expected outcomes of care. DIF: A REF: 221 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 8. The nurse has a multiple client assignment on the surgical unit. On beginning the shift, the nurse needs to determine which postoperative client should be seen first. Of the following, the nurse should go to see the client who: 1. Has a documented blood pressure of 90/50 2. Was medicated for back pain 10 minutes ago 3. Has an order to be out of bed and ambulated 4. Requires instructions for wound care before discharge ANS: 1 The nurse prioritizes actions and determines to see this client first because of a lower than normal blood pressure for a postoperative patient. This nurse is using scientifically and practice-based criteria for making clinical judgment. This is an example of following standards. The nurse uses criteria such as the clinical condition of the client, Maslow’s hierarchy of needs, and risks involved in treatment delays to determine which clients have the greatest priority for care. In answers 2 through 4, the client is not reported to be having any problems and therefore is not the priority. DIF: C REF: 221 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment/Coordination/Setting Priorities 9. There are a variety of levels of critical thinking. An example of critical thinking at the complex level is: 1. Giving medication at the time ordered 2. Following a procedure for catheterization step-by-step 3. Reviewing all clients’ medical records thoroughly 4. Discussing various alternative pain management techniques ANS: 4 Discussing alternative pain management techniques is an example of critical thinking at the complex level. The nurse analyzes and examines alternatives more independently. Giving medication at the time ordered is an example of the basic level of critical thinking. Following a procedure step-by-step is an example of the basic level of critical thinking. Reviewing the client’s medical records thoroughly is an example of gathering data and may be used in evaluation of a client’s care.
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
15-5
DIF: C REF: 218 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 10. The nurse is deciding on the type of dressing to use for a client. Which step of the decision-making process is being used when the nurse observes the absorbency of different dressing brands? 1. Defining the problem 2. Making final decisions 3. Testing possible options 4. Considering consequences ANS: 3 The nurse who observes the absorbency of different brands of dressing is demonstrating testing of possible options. This is not an example of defining the problem. The nurse has not yet made a final decision. The nurse is not examining pros and cons, and therefore is not considering consequences. DIF: A REF: 219 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 11. Which one of the following examples demonstrates the critical thinking attitude of responsibility and authority? 1. Reporting client difficulties 2. Offering an alternative approach 3. Looking for a different treatment option 4. Sharing ideas about nursing interventions ANS: 1 Reporting client difficulties demonstrates the critical thinking attitude of responsibility and authority. Asking for help if uncertain and following standards of practice also demonstrate the critical thinking attitudes of responsibility and authority. Offering an alternative approach would demonstrate the critical thinking attitude of risk-taking. Looking for a different treatment option demonstrates the critical thinking attitude of creativity. Sharing ideas about nursing interventions demonstrates the critical thinking attitude of thinking independently. DIF: A REF: 223 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 12. Use of the intellectual standard of critical thinking implies that the nurse: 1. Questions the physician’s order 2. Recognizes conflicts of interest 3. Listens to both sides of the story
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
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4. Approaches assessment logically ANS: 4 Use of the intellectual standard of critical thinking implies that the nurse approaches assessment logically and consistently. Questioning the physician’s order is an example of the critical thinking attitude of risk-taking. Recognizing conflicts of interest demonstrates the critical thinking attitude of integrity. Listening to both sides of the story demonstrates the critical thinking attitude of fairness. DIF: A REF: 225 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 13. A client requires urinary catheterization but has difficulty keeping her legs in the usual position needed for this procedure. The nurse has worked for many years and adapts the procedure to allow the client to lie on her side. This action is based on the critical thinking element of: 1. Curiosity 2. Experience 3. Perseverance 4. Scientific knowledge ANS: 2 Having worked for many years and being able to adapt a procedure to meet the client’s needs is an example of the second component of the critical thinking model—experience. Curiosity is a critical thinking attitude where the nurse asks why, and continues to learn more about the client to make appropriate clinical judgments. Perseverance is a critical thinking attitude where the nurse does not readily accept the easy answer but does look further to find necessary information and appropriate solutions. Scientific knowledge is knowledge acquired from the study of science. It may be acquired through education, such as coursework, or by reading nursing literature to remain current in nursing science. DIF: A REF: 222 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 14. Which of the following statements made by a nursing student concerning the use of critical thinking and client care requires follow-up by the nursing instructor? 1. “I feel it’s good practice to always have alternative interventions in mind.” 2. “I trust my feelings about a client’s needs since I work hard at knowing my client.” 3. “I always try to keep an open mind about what interventions my client will require.” 4. “I will wait until my assessment is completed before determining the client’s needs.” ANS: 2
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
15-7
Intuition develops as one’s clinical experience increases. The nursing instructor should instruct the student to examine rationales in order to make good decisions regarding client needs. The instructor would encourage the student to examine alternatives to meet the client’s unique needs, so this statement would not require follow-up. Basing client care on identified client needs is the appropriate use of critical thinking, and so would not require follow-up. Basing client care on client needs identified by thorough nursing assessments is the appropriate use of critical thinking, and so would not require followup. DIF: C OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 15. Which of the following is the best example of a nurse’s use of reflection? 1. The nurse places a client experiencing respiratory difficulties in a high-Fowler’s position. 2. The nurse calls the provider when a client reports feeling “chilled and achy” while having an oral temperature of 100.2° F. 3. While caring for a client with a history of asthma, the nurse assesses the client’s pulse oximetry reading when he “doesn’t sound right.” 4. A nurse tells a client; “When you refused to go to physical therapy earlier today I believe you were upset about something else besides the appointment time.” ANS: 4 Reflection is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. Knowledge of the nurse includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing. Scientific methodology is an approach to seeking the truth or ing that a set of facts agrees with reality. Intuition is an inner sensing that something is so, as in this example. DIF: C REF: 226 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 16. Which of the following nursing situations best reflects ability? 1. The nurse takes the oncology nursing certification examination. 2. The nurse files an incident report regarding a medication error. 3. The nurse assesses the client for the possible cause of his pain. 4. The nurse tells the client, “I don’t know but I will find out for you.” ANS: 2 To be able means to be answerable for the outcomes of your actions. Answer 2 is an example of the critical thinking attitude of risk-taking. A critical thinker is willing to take risks in trying different approaches to solving problems. To think independently, one questions others’ ways of interpreting knowledge and looks for rational and logical answers to problems. Humility is a critical thinking attitude where a person its what they do not know and tries to acquire the knowledge needed to make proper decisions.
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
15-8
DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 17. Which of the following nursing actions is the best example of problem solving? 1. Requesting the IV team to start an antibiotic drip on a client with a history of being a difficult stick 2. Offering to call the kitchen to provide an alternate breakfast for a client who does not like cooked cereal 3. Trying several difficult wound dressings to determine which one the client can apply the most effectively 4. Calling for another pain medication order when the current drug results in the client experiencing nausea ANS: 3 This is an example of the critical thinking strategy of problem solving. The nurse gathers information by using several different products and then uses this information to determine which will work best for the client. Effective problem solving involves the examination of alternatives. While requesting the IV team solves a problem, there is little critical thinking needed because it would be understood that the IV team would be called under these circumstances. Although calling the kitchen solves a problem, there is little critical thinking needed because it would be understood that the kitchen would be called under these circumstances. Calling for another pain medication order solves a problem, but there is little critical thinking needed because it would be understood that the provider would be called for a new drug order under these circumstances. DIF: C REF: 219 OBJ: Analysis TOP: Nursing Process: Assessment/Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 18. Which of the following clients should be prioritized with the most urgent need for a nursing assessment? 1. A new ission itted for swelling in the right ankle and knee 2. A second day postoperative client who received pain medication 30 minutes ago 3. A client who the nursing assistant found crying in the bathroom 4. A client ready for discharge who requires a final assessment and documentation ANS: 3 This client has an acute need that requires the nurse’s attention. The facility has a policy regarding the amount of time available in which to complete such an assessment and this client is in no acute distress, so the assessment does not have priority. While a pain assessment is required to evaluate the effectiveness of pain medication, it does not the have the priority of the other presented options. This client has no acute problems and so the assessment does not have the priority of some of the other options. DIF: C REF: 221 TOP: Nursing Process: Assessment
OBJ: Analysis
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
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MSC: NCLEX® test plan designation: Safe, Effective Care Environment 19. Which of the following nursing interventions is the best example of the implementation step of the nursing process? 1. Determining that the client’s ankle edema is worse after he ambulates 2. Asking the client to rate his ankle pain after receiving oral pain medication 3. Arranging for the client to receive pain medication 30 minutes before his ordered ambulation 4. Crushing the client’s pain medication to facilitate easier swallowing and thus minimize the risk of choking ANS: 4 Taking appropriate action demonstrates the implementation step of the nursing process. Assessment involves the gathering of data. Assessment involves the gathering of data. Planning involves establishing goals and expected outcomes of care. DIF: C REF: 221 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 20. Which of the following nursing actions best reflects the consequence stage of the decision-making process? 1. Being physically present when a client is given the results of a tissue biopsy 2. Witnessing the client sign consent for surgery forms before cardiac surgery 3. The client is informed of the various treatments available for his condition. 4. The nurse explains to the client the risks of leaving the hospital against medical advice. ANS: 4 The nurse is presenting the possible outcomes, and therefore is presenting consequences. Being physically present is not an example of defining the problem. Witnessing the client sign consent is an example of a final decision. In Answer 3 the client is being given various options. DIF: C REF: 219 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 21. The concept of nursing responsibility is best reflected in which of the following nursing actions? 1. Providing accurate and timely documentation regarding an incident resulting in a client fall 2. Suggesting that a client might prefer taking a particular medication at bedtime instead of in the morning 3. Posting a note on the unit Kardex how to best apply a dressing to a skin wound on a particular client 4. Referring to the institution’s policy manual when unsure of how to handle a client’s
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
15-10
complaint regarding a social services consult ANS: 4 Asking for help if uncertain and following standards of practice best demonstrate the critical thinking attitudes of responsibility because failure to do so could result in client injury. Reporting client difficulties demonstrates the critical thinking attitude of responsibility but is not the best option of those available because it would not result in client injury/harm. Offering an alternative approach would best demonstrate the critical thinking attitude of risk-taking. Sharing ideas about nursing interventions best demonstrates the critical thinking attitude of thinking independently. DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 22. Which of the following situations is the best example of a nurse using intellectual standards as a critical thinking tool? 1. Performing a head-to-toe assessment on a new ission 2. Placing a client experiencing shortness of breath on oxygen 3. Arbitrating a complaint between roommates over the television 4. Notifying a provider of a client’s allergy to an ordered medication ANS: 2 Use of the intellectual standard of critical thinking implies that the nurse approaches nursing care logically, consistently, and appropriately. This option reflects the use of such standards in a situation that addresses client distress. While performing a head-to-toe assessment is an example of intellectual standards, it is not the best example because it does not involve a client’s immediate distress. Listening to both sides of the story demonstrates the critical thinking attitude of fairness. Notifying a provider of a client’s allergy is an example of nursing responsibility. DIF: C REF: 225 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 23. The nurse is best demonstrating perseverance by: 1. Having a perfect attendance record 2. Completing a lengthy course on current chemotherapies 3. Repeatedly irrigating the nasogastric tube until it is patent 4. Sitting with a client until she is ready to discuss why she is crying ANS: 4
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
15-11
Perseverance is a critical thinking attitude in which the nurse does not readily accept the easy answer but does look further to find necessary information and appropriate solutions. While perfect attendance shows a nurse’s willingness to complete the work responsibilities regardless of barriers, it is a better representation of responsibility. While completing a course on current chemotherapies shows the nurse’s willingness to pursue knowledge, it is more representative of the acquiring of scientific knowledge to remain current in nursing science. While repeatedly irrigating the nasogastric tube shows a willingness to repeat a procedure as often as is appropriate, it is a better representation of possessing knowledge of the procedure. DIF: C REF: 224 OBJ: Analysis TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Safe, Effective Care Environment 24. With regards to client care, the most likely reason that a veteran nurse tends to be a more skillful critical thinker than a new graduate nurse is because: 1. The veteran nurse has a varied history of client care experiences 2. Critical thinking improves with experience, longevity, and interest 3. Today’s short hospital stays minimize the opportunity to develop critical thinking skills 4. New graduates often lack the self-confidence to take the risks often required of critical decision making ANS: 2 Critical thinking is not a simple step-by-step, linear process that you learn overnight. It is a process acquired only through experience, commitment, and an active curiosity toward learning. While experience is a factor in the development of critical thinking skills, it is not the only factor. While having extended periods of time with clients has a positive effect on the development of critical thinking, it is not the primary or sole factor. While lack of self-confidence may have a negative effect on the development of critical thinking skills, it is not the primary or sole factor. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 25. The primary factor that distinguishes a professional nurse’s care from care provided by ancillary nursing staff is: 1. Critical thinking 2. Years of education 3. Professional licensure 4. Complexity of the task ANS: 1
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
15-12
Clinical decision making separates professional nurses from technical personnel. While advanced education is a distinction, the primary factor regarding client care is the professional nurse is responsible for actions that require critical thinking decision making. Although licensure is a distinction, the primary factor regarding client care is the professional nurse is responsible for actions that require critical thinking decision making. 4. While complexity is a distinction, the primary factor regarding client care is that the professional nurse is responsible for actions that require critical thinking decision making. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 26. A clinical nursing instructor asks the nursing students to describe a critical thinker. Which of the following represents the best response? 1. “A person with the educational background to solve problems.” 2. “A person who finds the problem and does what is best to fix it.” 3. “It’s someone who uses the scientific method to solve problems.” 4. “Someone who uses a system to work through and solve a problem.” ANS: 2 A critical thinker considers what is important in a situation, imagines and explores alternatives, considers ethical principles, and then makes informed decisions. Educational background may have an impact on critical thinking but it is not the primary or sole factor to consider. Although the scientific method is often used in critical thinking it is neither the only method nor the sole factor to consider. While an orderly method is used in critical thinking, it is not the only factor to consider. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 27. Which of the following statements made by a new graduate nurse regarding a client’s care needs requires follow-up by the mentor? 1. “No one really enjoys being hospitalized.” 2. “Every client is offered a back rub at bedtime.” 3. “All post surgery clients are reluctant to ambulate.” 4. “I always spend extra time with new clients to help them relax.” ANS: 3 Because no two clients respond exactly alike to similar health problems, you always have to observe each client closely in order to make critically sound decisions regarding that client’s needs. Answer 1 does not require follow-up because even if it is not true, it does not have an impact on the nurse’s perception of the client’s care needs. Answer 2 does not require follow-up because it is a nursing action that should be offered to all clients at bedtime.
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
15-13
Answer 4 does not require follow-up because it is a nursing action that should be offered to all clients. DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 28. A nurse is caring for an immobile client with a large pressure ulcer on her left ankle. Which of the following statements by the nurse best reflects critical thinking regarding client care? 1. “I’m sure that friction and pressure have caused this problem.” 2. “Please be sure that her ankles are well padded when you place her in bed.” 3. “Do you have any suggestions on how we can minimize the pressure to her ankles?” 4. “It was an ineffective turning schedule that allowed this to happen so now we will reposition every hour.” ANS: 3 Nurses who apply critical thinking in their work focus on options for solving problems and making decisions, rather than quickly and carelessly forming quick solutions. Asking for staff input regarding interventions shows critical thinking. While Answer 1 may be true, it is knowledge or experience, not critical thinking, that brought about this conclusion. Although Answer 2 may represent an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion. While Answer 4 may be true and an example of an appropriate intervention, it is knowledge or experience, not critical thinking, that brought about this conclusion. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Safe, Effective Care Environment 29. A nurse is caring for a 35-year-old client who is 12 hours post mastectomy. The care assistant reports that the client is crying. Which of the following responses by the nurse best reflects the use of analysis regarding this client’s care needs? 1. “That surgery is painful. I’ll get her pain medication ready.” 2. “She was sleeping when I checked 15 minutes ago. I’ll go back in right now.” 3. “I’ll be responsible for her PM care so I can spend some uninterrupted time with her.” 4. “A mastectomy is a blow to a woman’s self image. I’ll notify her provider that she is depressed.” ANS: 2
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
15-14
Analysis requires being opened-minded as you look at information about a client. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options? Although pain may be the cause of this client’s tears, there are other possible reasons, so making an assumption is not appropriate. Although Answer 3 shows the nurse’s intention to analyze the client’s needs, the delay is not appropriate. While the client may be experiencing some depression, there are other possible reasons for the tears and so the nurse should not assume. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment 30. Which of the following statements made by a nurse regarding personal reflection related to client care requires follow-up by the unit’s nurse manager? 1. “Mary and I were comparing foot wound dressing techniques.” 2. “I’ve been caring for orthopedic clients for 10 years and I think I’ve seen it all.” 3. “I can’t believe that my client isn’t improving after 2 weeks of physical therapy.” 4. “I always wean my orthopedic surgery clients onto oral pain medication on postoperative day 4.” ANS: 4 Reflect on your experiences. Identify the ways you can improve your own performance. This option presents a rigid attitude concerning client pain needs. Answer 1 needs followup because it shows a willingness to explore other’s opinions. Answer 2 requires no follow-up because it does not reflect an inflexible attitude toward client care need. Answer 3 requires no follow-up because it does not reflect an inflexible attitude toward client care needs. DIF: C REF: 217 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment MULTIPLE RESPONSE 1. The scope of a client’s health problem is a result of which of the following factors? (Select all that apply.) 1. Religious beliefs 2. Life experiences 3. Lifestyle choices 4. Work environment 5. Family relationships 6. Educational background ANS: 2, 3, 4, 5 Each client’s problems are unique and a product of many factors, including the client’s physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences. Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
Test Bank
DIF: C REF: 216 OBJ: Analysis TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Safe, Effective Care Environment
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an of Elsevier Inc.
15-15
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