A nurse who is caring for a patient with a pressure ulcer applies the
recommended dressing according to hospital policy. Which standard is the nurse
... [Show More] following?
Fairness
Intellectual standards
Independent reasoning
Institutional practice guidelines
ANS: D
The standards of professional responsibility that a nurse tries to achieve are the standards cited in Nurse Practice Acts, institutional practice guidelines (hospital/facility policy), and professional organizations’ standards of practice (e.g., The American Nurses Association Standards of Professional Performance). Intellectual standards are guidelines or principles for rational thought. Fairness and independent reasoning are two examples of critical thinking attitudes that are designed to help nurses make clinical decisions.
A nurse is reviewing care plans. Which finding, if identified in a plan of
care, should the registered nurse revise?
Patient’s outcomes for learning
Nurse’s assumptions about hospital discharge
Identification of several actual health problems
Documentation of patient’s ability to meet the goal
ANS: B
The nurse should not assume when a patient is going to be discharged and document this information in a plan of care. Making assumptions is not an example of a critical thinking skill. The purpose of the nursing process is to diagnose and treat human responses (e.g., patient symptoms, need for knowledge) to actual or potential health problems. Use of the process allows nurses to help patients meet agreed-on outcomes for better health. The
patient’s outcomes, having several actual health problems, and a description 1
of the patient’s abilities to meet the goal are all appropriate to document in the
nursing plan of care.
In which order will the nurse use the nursing process steps during the clinical decision-making process?
Evaluating goals
Assessing patient needs
Planning priorities of care
Determining nursing diagnoses
Implementing nursing interventions a. 2, 4, 3, 5, 1
b. 4, 3, 2, 1, 5
c. 1, 2, 4, 5, 3
d. 5, 1, 2, 3, 4
ANS: A
The American Nurses Association developed standards that set forth the framework necessary for critical thinking in the application of the five-step nursing process: assessment, diagnosis, planning, implementation, and evaluation.
MULTIPLE RESPONSE
Which findings will alert the nurse that stress is present when making
a clinical decision? (Select all that apply.)
Tense muscles
Reactive responses
Trouble concentrating
Very tired feelings
Managed emotions
ANS: A, B, C, D
Learn to recognize when you are feeling stressed—your muscles will tense, you become reactive when others communicate with you, you have trouble concentrating, and you feel very tired. Emotions are not managed when stressed.
2 [Show Less]