HESI A2 Critical Thinking(Nursing) Questions and Answers | GRADED A

HESI A2 Critical Thinking(Nursing) Questions and Answers | GRADED A What are the 5 steps of the Nursing Process? Correct Answer: Assessment, Diagnosing/Analyzing data gained from assessing/Planning (including outcome identification), Implementing (according to priority), evaluating...did it work? The nursing process is... Correct Answer: overlapping and dynamic What does P-I-E stand for? Correct Answer: Problem, Implement, Evaluate What is the acronym COVD used for? Correct Answer: Used during assessing? Collecting Data Organizing Data Validating Documenting Data What are the sources of data that you retrieve during assessment? Correct Answer: patient, support peoples, client records What type of client records could you get data from? Correct Answer: Other healthcare professionals, nursing and scientific literature What are the two types of data you will take from the patient? Correct Answer: Subjective and Objective data What is subjective data? Correct Answer: Data that only the subject or "patient" can feel and will tell you. Usually in a statement. What is objective data? Correct Answer: What you observe and can measure Besides measurable data for your objective data, what other objective data should you collect? Correct Answer: What you see, hear, and smell. What do you do with your data sometimes if it is off or you are to sure of it? Correct Answer: VALIDATE How do you record subjective data? Correct Answer: In clients, "own words." What does the diagnoses do? Correct Answer: Describes the patients health problem in nursing terminology - NOT medical. What are some qualifiers for diagnoses? Correct Answer: deficient, impaired, decreased, ineffective or compromised What is etiology? Correct Answer: The "related to" part....it is NURSE FIXABLE? What does the etiology or "related to" part do? Correct Answer: Directs the nursing intervention What does the correctly stated nursing problem have....PES....? Correct Answer: Problem Statement (NANDA) only, Etiology "related to", and the supporting data (subj. obj assessment findings) What is planning? Correct Answer: involved determining pt goals/outcomes You cannot have an intervention.... Correct Answer: without a goal. You cannot have a goal... Correct Answer: without an intervention A goal is a direct result of an... Correct Answer: intervention When planning what do you always want to do? Correct Answer: BE SPECIFIC...WHO, WHAT, WHEN, HOW OFTEN, HOW MUCH For every nursing diagnoses....the nurse... Correct Answer: must write atleast one desired outcome The purpose of an intervention... Correct Answer: is a goal! What is an evaluation mean? Correct Answer: A patient response to an intervention Risk Factors Correct Answer: do not have defining characteristics....they are not specific Between an intervention and a goal...there is... Correct Answer: TEACHING In a care plan... Correct Answer: there is always a reference in APA format Actual nursing diagnoses Correct Answer: a client problem present at time of assessment Risk nursing diagnoses Correct Answer: clinical judgement that problem doesn't exist, but presence of risk factors indicates problem may develop Wellness Correct Answer: readiness for enhancement The etiology is always... Correct Answer: nurse fixable Standing Orders Correct Answer: written documentation authorizing nurse to carry out specific actions under ceratin circumstance standardized care plan Correct Answer: formal plan that specifies nursing care for a group of clients with common needs Individual care plans Correct Answer: tailored to meet unique needs of pt What are the five components of the goal? Correct Answer: Subject, Verb, Criteria, Condition, Time The client, will ambulate, fifty feet in the hall, one time with assistance, by 4pm. What can you do by for your goals! Correct Answer: BMAT...behavior, measure, condition, time About Rationales Correct Answer: By each nursing intervention...put page number of rationale... When evaluating, what do you think about? Correct Answer: What it effective, ineffective, were goals met, not met, partially met? Critical Thinking Correct Answer: Is an active, organized, cognitive process used to examine one's thinking and the thinking of others. Evidenced-based knowledge Correct Answer: Based on research or clinical expertise Identify the concepts and behaviors of a critical thinker. Truth seeking: Correct Answer: Seek the true meaning of a situation Identify the concepts and behaviors of a critical thinker. Open-mindedness: Correct Answer: Be tolerant of different views and own prejudices Identify the concepts and behaviors of a critical thinker. Analyticity: Correct Answer: Anticipate possible results or consequences Identify the concepts and behaviors of a critical thinker. Systematicity: Correct Answer: Be organized Identify the concepts and behaviors of a critical thinker. Self-confidence: Correct Answer: Trust in your own reasoning processes Identify the concepts and behaviors of a critical thinker. Inquisitiveness: Correct Answer: Be eager to acquire new knowledge and value learning Identify the concepts and behaviors of a critical thinker. Maturity: Correct Answer: Reflect upon your own judgments Name Three levels of critical thinking. Correct Answer: Basic, Complex, Commitment Describe the Basic Level of Critical Thinking. Correct Answer: Trust that experts have the right answers for every problem; thinking is concrete and based on a set of rules or principles Describe the Complex Level of Critical Thinking. Correct Answer: Begin to separate themselves from authorities, analyze and examine choices more independently. Describe the Commitment Level of Critical Thinking. Correct Answer: Anticipate the need to make choices without assistance from others, accountability Scientific method Correct Answer: Systematic, ordered approach to gathering data and problem solving Problem Solving Correct Answer: Evaluating the solution over time to make sure it is effective Decision making Correct Answer: Focuses on problem resolution Diagnostic reasoning Correct Answer: Determining a client's health status after you have assigned meaning to the behaviors and symptoms presented Inference Correct Answer: Process of drawing conclusions from related pieces of evidence Clinical decision making Correct Answer: Careful reasoning so that the best options are chosen for the best outcomes Nursing process Correct Answer: Five-step clinical decision-making approach List the five components of critical thinking Correct Answer: Knowledge, Experience, Critical Thinking Competencies, Attitudes, Standards Critical Thinking Attitudes. Confidence: Correct Answer: Speak with conviction and always be prepared to perform care safely Critical Thinking Attitudes. Thinking independently: Correct Answer: Reads the Nursing Literature Critical Thinking Attitudes. Fairness: Correct Answer: Listen to both sides in any discussion Critical Thinking Attitudes. Responsibility: Correct Answer: Refer to policy and procedure manual to review steps of a skill Critical Thinking Attitudes. Risk Taking: Correct Answer: Be willing to recommend alternative approaches to Nursing Care Critical Thinking Attitudes. Discpline: Correct Answer: Take time to be thorough, and manage your time effectively Critical Thinking Attitudes. Perseverance: Correct Answer: Be cautious of an easy answer, look for a pattern and find a solution Critical Thinking Attitudes. Creativity: Correct Answer: Look for different approaches if interven tions are not working Critical Thinking Attitudes. Curiosity: Correct Answer: Explore and learn more about a client to make appropriate clinical judgments Critical Thinking Attitudes. Integrity: Correct Answer: Do not compromise nursing standards or honesty in delivering nursing care Critical Thinking Attitudes. Humility: Correct Answer: Recognize when you need more information to make a decision What are the two Standards used in the Critical Thinking Model. Correct Answer: Intellectual & Professional Explain the Standard "Intellectual" used in the Critical Thinking Model. Correct Answer: Is a guideline or principle for rational thought Explain the Standard "Professional" used in the Critical Thinking Model. Correct Answer: Refers to ethical criteria for nursing judgments; evidence-based used for evaluation and criteria for professional responsibility Reflective Journaling Correct Answer: Is the process of purposefully thinking back or recalling a situation to discover its purpose or meaning Concept Mapping Correct Answer: Is a visual representation of client problems and interventions that shows their relationships to one another Reflection Correct Answer: Process of thinking back or recalling an event or discovering the meaning and purpose of that event. Prognosis Correct Answer: A prediction of the probable outcome of a disease or condition of a client and the usual course of the disease as observed in similar situations Assessment Correct Answer: The first step of the nursing process Purposes of Nursing Assessment Correct Answer: 1.Establish a baseline of info. about the client 2.Determine the patient's normal function 3.Determine the presence or absence of dysfunction 4.Determine the patient's strengths 5.Provide data for the diagnosis phase Purpose of Nursing Assessment: "Triple D" E and P Correct Answer: 1.Determine patient's normal function 2.Determine the presence or absence of dysfunction 3.Determine patient's strengths 4.Establish a baseline of information about the client 5.Provide Data for the diagnosis phase Assessment techniques Correct Answer: vation view nation al record review Dimensions for Gathering Data for Health History Correct Answer: Physiological and Developmental, Psychological, Sociological, Spiritual Physiological and Developmental Correct Answer: 1.Perception of health status 2.Past health problems and therapies 3.Present of health therapies 4.Risk Factors 5.Activity and coordination 6.Review of Systems 7.Developmental Stage 8.Effect of health status on developmental stage 9.Growth and maturation 10.Occupation 11.Ability to complete ADL's Psychological Correct Answer: 1. Behavioral and emotional status 2.Support Systems 3.Self Concept 4.Body Image 5.Mood 6. Sexuality 7.Coping Mechanisms Sociological Correct Answer: 1.Financial Status 2.Recreational Activities 3.Primary Language 4.Cultural Heritage 5.Cultural Influences 6.Community Resources 7.Environmental Risk Factors 8.Social Relationships 9.Family Structure and Support Spiritual Correct Answer: 1.Beliefs and meaning 2.Religious experiences 3.Rituals and practices 4.Fellowship 5.Courage Six Key Phases of Assessment Correct Answer: 1.Collecting Data 2.Identifying Cues and making inferences 3.Validating the Data 4.Organizing (Clustering) the Data 5.Identifying Patterns and Testing First Impressions 6.Reporting and Recording Data Collecting Data Correct Answer: Subjective, Objective, Judgements, Conclusions, Opinions, and Care Plan Subjective Data Correct Answer: Symptoms or overt cues that include the patient's feelings, perceptions, concerns and statements about his/her health problems -supplied by the patient -not always feasible to validate or confirm through other sources -Data obtained through the interview and is best recorded as quotes Objective Data Correct Answer: Overt cues that are observable, perceptible, and measurable -Can be validated by others -Examples such as BS, PR, skin rashes -May be obtained by senses by measuring devices such as thermometers, monitors Judgements, Conclusions, and Opinons Correct Answer: 1.Interpretations of data by one nurse 2.Data may mean different things to different nurses 3.Not concise or descriptive 4.May leave room for interpretation of meaning 5.Don't want to use judgements, conclusions, or opinions in assessment data Identifying Cues and Making Inferences Correct Answer: The nurse recognizes significant data and draws some basic conclusions about what the data may indicate Cues Correct Answer: *the subjective and objective data you gathered act as cues *Data that prompt you to get a beginning impression of patterns of health or illness *Conclusions you draw about cues=inferences Examples of Cues Correct Answer: "I don't want to talk"-May be Depressed Blood Pressure 70/40-May be in shock Validating the Data Correct Answer: 1.Confirm the accuracy of the data collected 2.Comparing cues to normal function 3.Referrring to texts, articles, reports 4.Checking consistency of cues 5.Clarifying statements 6.Seeking consensus with colleagues re:inferences Validating Data Helps the Nurse Avoid Correct Answer: 1.Making assumptions 2.Missing key info. 3.Misunderstanding the situation 4.Jumping to conclusions or focusing in the wrong direction 5.Making errors in problem identification Organizing (Clustering) the Data Correct Answer: -Utilize the human needs framework and nursing process format 1.Organizes data into meaningful clusters 2.A set of signs or symptoms that are grouped together in a logical order 3.Helps to focus on the identification of the correct patient problem 4.Cues that alert the nurse to help in the generation of the nursing diagnosis 5.Use Human Needs Framework for deciding about nursing concerns 6.Use Maslow for deciding about priorities Identifying Patterns and Testing First Impressions Correct Answer: -Initial impression of patterns -Test the impressions and decide if the patterns really are as they appear -Decide what is relevant and focus assessment to gain more information -Ask yourself what relevant information might be missing Reporting and Recording Data Correct Answer: a.Continuity-Communicate by reporting what you know b.Accuracy-Timely reporting will keep you from forgetting-write your notes as you go c.Critical Thinking-Reporting key data will help others in this problem solving process Reporting and Recording-Guidelines to Follow: Correct Answer: a.When in doubt, ask your instructor or nurse b.Report abnormal findings as soon as possible c.Before reporting make sure you have all necessary info. at hand d.Write down your report e.Give precise info.-state the facts not your interpretation f.USE SBAR SBAR Correct Answer: S: Situation B: Background A: Assessment R: Recommendation Types of Assessment Correct Answer: 1.Initial Assessment 2.Focus Assessment 3.Time-Lapsed Reassessment 4.Emergency Assessment Initial Assessment Correct Answer: -Admission when client enters healthcare system -Purpose to evaluate health status and identify health needs that are unmet -Must be documented by registered nurse -Parts may be delegated to non-licensed personnel Focus Assessment Correct Answer: To collect data about a problem already identified. Also includes the appraisal of any new, overlooked, or misdiagnoses problems Time-lapsed Reassessment Correct Answer: -Evaluate any changes in patient's human needs -Performed when long periods of time have elapsed between assessments (3-12mo) -Less comprehensive than initial assessment Emergency Assessment Correct Answer: Life-threatening situations-ABC, suicidal thoughts, social conflict leading to violent acts Planning the Interview Correct Answer: -Time: pt should be physically comfortable and free from pain -Place: have adequate privacy -Seating arrangement: 45% angle of bed -Distance: 3-4 ft away Stages of the Interview Correct Answer: 1.Opening 2.Body of the Interview 3. Closing (Termination) Opening Correct Answer: This is where you will establish rapport, give orientation to what you will be talking about Bod of the Interview Correct Answer: This is where you will ask open-ended questions and gather data for you to be able to give the best possible nursing care Closing (Termination) Correct Answer: 1.Offer to answer any further questions 2.Declare completion of the task 3.State appreciation with what was accomplished 4.Express concern for person's welfare/future 5.Reveal what will happen next and signal time 6.Provide a summary to verify accuracy Physical Assessment Correct Answer: You will then move into the physical assessment portion of the Assessment Phase Nursing Process Five Step Problem Solving Process Correct Answer: 1.Assessment 2.Analysis/Diagnosis 3.Planning 4.Implementation 5.Evaluation Nursing Process Correct Answer: The foundation that characterizes nursing and how nurses think. -A means to meeting the Standards of Nursing Clinical Practice as published by the ANA (1998) Standard 1: Assessment Correct Answer: "The nurse collects pt health data-the nurse continuously collects data about health status to monitor for evidence of health problems and risk factors