Nokea
Successful implementation of each step of the nursing process requires high-level skills in critical thinking. Which of the following statements accurately describe a guideline for using this process?
- A. Trust clinical judgment and experience over asking for help.
- B. Respect clinical intuition, but never allow it to determine a diagnosis.
- C. Recognize personal biases as a strength in formulating diagnoses.
- D. Keep an open mind and trust your intuition when formulating diagnoses.
Correct Answer: D
Rationale: Keeping an open mind and trusting intuition, while validating with data, supports effective critical thinking in the nursing process.
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A nurse observes a new mother tenderly holding and softly talking to her baby. What does this observation tell the nurse about the babys strengths?
- A. Nothing; this observation is not important.
- B. The mother is just behaving as all mothers do.
- C. A baby is not capable of having strengths.
- D. Nurturing is a strength for developing infants.
Correct Answer: D
Rationale: Positive maternal interaction, such as nurturing, supports the infant's emotional and developmental strengths.
In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side of face, what part of the nursing diagnosis is presence of large scar over left side of face?
- A. etiology
- B. problem
- C. defining characteristics
- D. patient need
Correct Answer: A
Rationale: The 'presence of large scar' is the etiology, as it describes the cause of the disturbed self-esteem.
A nurse caring for an elderly patient in a long-term care facility notices that the bedding is wet when the patient gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?
- A. no problem
- B. possible problem
- C. actual problem
- D. clinical problem
Correct Answer: B
Rationale: Wet bedding suggests a possible problem, such as incontinence, but further data collection is needed to confirm.
A nurse develops a plan of care to meet the needs of a patient who has had a large loss of blood after a snowmobile crash. The interventions include administering and monitoring the patients physiologic response to intravenous fluids and blood. What has the nurse focused care on?
- A. a medical diagnosis
- B. a nursing diagnosis
- C. a collaborative problem
- D. a goal for care
Correct Answer: C
Rationale: This scenario describes a collaborative problem, as it involves joint interventions between nursing and medical care, such as administering fluids and blood.
In addition to identifying responses to actual or potential health problems, what is another purpose of the diagnosing step in the nursing process?
- A. to collect information about subjective and objective data
- B. to correlate nursing and medical diagnostic criteria
- C. to identify etiologies of health problems
- D. to evaluate mutually developed expected outcomes
Correct Answer: C
Rationale: Identifying etiologies of health problems is a key purpose of the diagnosing step, as it helps determine the underlying causes of a patient's health issues, guiding appropriate interventions.