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10 Cards in this Set
- Front
- Back
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A nurse is caring for a client of a different culture. The nurse is not familiar with the customs of this particular client and becomes disturbed when the client's spouse makes all the decisions about care and treatments. The nurse's reaction is an example of which of the following?
A) Judgment B) Inference C) Evaluation D) Opinion |
D
Opinions are beliefs formed over time and include judgments that may fit facts or be in error. In this case, the nurse may not understand that culturally, this may be very appropriate and fitting for this client. If this is the case, the nurse should not become disturbed by the spouse's attention. Inferences are conclusions drawn from the facts, going beyond facts to make a statement about something not currently known. Judgment is an evaluation of facts or information that reflects values or other criteria; it is a type of opinion. Evaluation is considering the results or outcome. |
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A nurse is being questioned by the parents of a client whose physician ordered a battery of invasive tests. They are wondering why their child should have to go through all the pain and discomfort of these studies. The nurse is not familiar with the situation and has just come on duty for the evening shift. A limited report was given by the previous shift. The nurse understands that the child is stable at this time and has no pain, but the nurse has not been able to review the chart or do an initial assessment at this point. The best response by the nurse is:
A) "Your child's doctor is the best there is. I don't see why you wouldn't follow his advice." B) "I'm not sure I can answer your question just now." C) "It's a good idea to listen to what your physician wants." D) "Maybe you should get another opinion if you're not comfortable with your doctor." |
B
Suspending judgment means tolerating ambiguity for a time. If an issue is complex it may not be resolved quickly and judgment should be postponed. In this case, the nurse just doesn't have enough information to give a good answer to the parents. For a while, the nurse will need to say, "I don't know" and be comfortable with that answer. Telling the parents to agree with the physician before the nurse knows all the facts might be premature, even if he is the best physician in the area. It would also be premature to tell the parents to get another opinion. Nurses should not give advice or counsel, merely information. |
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A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 6 is least priority).__________ Family is at bedside.<__________ The IV pump is running on battery.__________ ECG monitor shows tachycardia.__________ Client is pale and restless.________ O2 tubing is not attached to wall regulator.__________ Bedding is damp and soiled.
A) 1,3,6,5,4,2, B) 5,3,1,2,4,6 C) 6, 4, 2, 1, 3, 5 D) 6,1,4,2,3,5 |
C
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The nurse is reviewing the client care plan and checking the quality of the nursing diagnosis statements. Criteria to use for guidelines in formulating nursing diagnoses include which of the following? (select all that apply)
A) stated in terms of a need B) nonjudgmental statements C) Word the diagnosis specifically and precisely D) Must be legally advisable E) cause and effect are correctly stated |
C, D, E
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A nurse educator senses that a student has been struggling with clinical skills learned in lab. In the clinical area, this student is usually lagging behind and seems to be involved when the other students have opportunities to perform some of the tasks. The educator pairs the student with a particularly outgoing staff nurse who has a number of unique clients with a variety of treatments and cares. The educator is utilizing which type of problem solving?
A) Experience B) Intuition C) Research process D) Trial and error |
B
Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as the sixth sense, hunch, instinct, feeling, or suspicion. In this case, the educator has a sense that the student is struggling, though there are no real facts to support it. Experience is part of intuition, but by itself, not a particular way to problem solve. Trial and error uses a number of approaches until a solution is found, which is not the case here. Trial-and-error methods in nursing care can be dangerous because the client might suffer harm if an approach is inappropriate. The research process is a systematic, analytical, and logical way to problem solve. |
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A client comes into the clinic with complaints of "extreme" low back pain after helping to move a heavy object. The client is pale and diaphoretic and walks bent at the waist. Before taking vital signs, the nurse projects that the blood pressure as well as heart rate will be elevated. This is an example of which of the following?
A) Fact B) Judgment C) Inference D) Opinion |
C
Inferences are conclusions drawn from facts, going beyond facts to make a statement about something that is not currently known. In this case, acute, severe pain will most likely cause the blood pressure as well as pulse rate to be elevated as the body's response to the painful experience. Fact can be verified through investigation. In this case, fact would be the elevated pulse and blood pressure readings. Judgment is evaluating facts and information that reflect values or other criteria; it is a type of opinion. Because the nurse understands the pathophysiology of pain, thinking about changes in vital signs is more than a judgmentit is an inference. Opinions are beliefs formed over time and include judgments that may fit facts or be in error. |
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The student nurse is learning the Taxonomy II nursing diagnoses system. This system is coded according to which of the following axes? (Select all that apply.)
A) Gordon's health pattern groupings B) Time C) Gender D) Age E) Health status F) Unit of care |
B, D, E, F
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A nurse is performing an initial assessment on a new admission. Which of the following is part of the database?
A) Reports from physical therapy the client received as an outpatient B) Documentation of the nurse's physical assessment C) A list of current medications D) Information about the client's cultural preferences E) All of the above |
E
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The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions. Which of the following data would support this diagnosis?
A) Skin is dry, cracked B) One large with several smaller open, ulcerated areas on right leg C) Clothes are soiled D) Client has obvious body odor E) All of the above |
E
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A nursing student is learning how to implement the nursing process in the clinical area. The purpose of the diagnosis phase includes which of the following? (Select all that apply.)
A) Develop a list of problems B) Identify client strengths C) Develop a plan D) Specify goals and outcomes E) Identify problems that can be prevented |
A, B, E
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