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The nursing assessment of a patient with a diagnosis of anorexia nervosa reveals the patient consumes a vegan diet of 700 calories daily and has lost 30 lb in 4 months. The nurse's recommendation to meet with a nutritionist is the outcome of which process?
- A. Clinical judgment
- B. Nursing process
- C. Clinical reasoning
- D. Critical thinking
Correct Answer: A
Rationale: Clinical judgment is the outcome of critical thinking and clinical reasoning, using the nursing process as a framework. Clinical reasoning refers to ways of thinking about patient care issues including weighing and validating options (determining, preventing, and managing patient problems). Critical thinking includes reasoning both outside and inside of the clinical setting.
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A nurse working in a long-term care facility reviews the electronic health records of patients who have fallen in the last month to determine if there is a common risk factor. Which QSEN competency is the nurse demonstrating?
- A. Patient-centered care
- B. Evidence-based practice
- C. Teamwork and collaboration
- D. Informatics
Correct Answer: D
Rationale: Informatics uses information and technology to communicate, manage knowledge, mitigate error, and support decision making. Thoughtful, patient-centered care emphasizes recognition of the patient or designee as the source of control and full partner in compassionate and coordinated care, based on respect for patients' preferences, values, and needs. Evidence-based practice integrates the best current evidence with clinical expertise and patient and family preferences and values to deliver optimal health care. Teamwork and collaboration refer to effective functioning within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.
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.
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.
When implementing a thoughtful, patient-centered care plan, which action does the nurse prioritize?
- A. The patient's loved ones are considered part of the team.
- B. A caring relationship with mutual trust is established.
- C. Measures for safety are visibly incorporated.
- D. Transparent communication is observed.
Correct Answer: C
Rationale: Although developing a thoughtful, patient-centered approach is focused on caring and mutual trust, the nurse uses the nursing process and Maslow's hierarchy of needs to prioritize care. Safety is a higher-level need than love and belonging, and therefore the priority.
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.