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A new graduate nurse phones the surgeon to report their patient is having severe incisional pain. The surgeon asks about vital signs and appearance of the wound, causing the nurse to return to the bedside for additional assessments. Upon reflection with the preceptor, which characteristic of the nursing process should the nurse have remembered?
- A. Centric
- B. Dynamic
- C. Interpersonal
- D. Systematic
Correct Answer: D
Rationale: The nursing process is systematic, iterative, and overlapping. By reporting an isolated symptom, the nurse has overlooked the benefit of systematic and inclusive assessment. While the nursing process is presented as an orderly progression of phases, there is a dynamic interaction and flow of phases into one another.
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A nursing student is committed to providing thoughtful, person-centered care. Which nursing actions demonstrate this type of care? Select all that apply.
- A. Assisting patients to select meals based on their cultural observances
- B. Providing nursing care based on patients' needs and preferences
- C. Documenting nursing interventions in the electronic health record
- D. Reviewing fingerstick blood glucose levels with the primary nurse
- E. Listening to a patient's concern for their ill significant other
Correct Answer: A,B,E
Rationale: The nursing process ensures that nurses are person centered rather than task centered. Attending to cultural preferences and needs and listening to a patient's concerns are patient-centered actions. Documentation and communication with other members of the health care team are not specifically patient centered.
The nurse is formulating a care plan for a patient in a long-term care facility who has lost 12 lb in the last 2 months. To arrive at a patient-centered nursing judgment, what will the nurse do first?
- A. Ensure the patient is receiving foods they like, including favorites.
- B. Make sure the patient's dentures are clean and inserted at mealtimes.
- C. Assess the patient's food intake and hydration over the last 1 to 3 days.
- D. Request that the nursing assistant feed the client at mealtime.
Correct Answer: C
Rationale: The nurse uses the nursing process to arrive at a clinical judgment. After analyzing the assessment data, the nurse determines, through clinical reasoning, whether the related factors in the patient's weight loss, such as dislike of menu options, lack of dentition, or inability to perform activities of daily living such as feeding, should be the focus of interventions.
An oncology nurse is analyzing a patient's strengths and finds the patient is well educated, learns quickly, and is resilient. In which phase of the nursing process will the nurse use this information?
- A. Diagnosing
- B. Evaluating
- C. Planning
- D. Implementing
Correct Answer: C
Rationale: Assessing for strengths and weaknesses is the first step of the nursing process, which has been completed. Next, the nurse clusters cues and develops diagnoses that give rise to interventions. Evaluating the plan is followed by completing or modifying the plan.
The nursing philosophy in an acute care hospital includes a commitment to deliver thoughtful, person-centered care. Which description of the nursing process best supports this commitment?
- A. Systematic
- B. Interpersonal
- C. Dynamic
- D. Universally applicable in nursing situations
Correct Answer: B
Rationale: Interpersonal. All other options are characteristics of the nursing process but focus on the patient best illustrates the interpersonal dimension of the nursing process.
A staff nurse tells a new graduate nurse not to bother studying too hard, since most clinical reasoning becomes second nature and intuitive once they begin practicing. Which response by the student is appropriate?
- A. Intuitive problem solving comes with years of practice and observation based on nursing knowledge and science.
- B. For nursing to remain a science, nurses must continue to be vigilant about avoiding intuitive reasoning.
- C. The emphasis on logical, scientific, evidence-based reasoning has held nursing back; we need intuitive, creative thinkers.
- D. The nurse's preference dictates whether they are logical, scientific thinkers or intuitive, creative thinkers.
Correct Answer: A
Rationale: When intuition is used alone, increased risks and fewer benefits may occur. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. There is a place for intuitive reasoning in nursing, but it will augment, not replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.