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During the change-of-shift report the night nurse states that a client mentioned having a bad experience

with surgery in the past. The nurse was called away and was unable to continue the conversation with
the client. The nurse tells the day shift nurse about the comment and notes that the client appears
anxious. When the day shift nurse visits the client to clarify the client's bad experience with surgery, the
nurse is exhibiting which aspect of critical thinking?

A. Integrity

B. Discipline

C. Confidence

D. Perseverance

D. Discipline

Discipline includes completing the task at hand, including assessments (which were not completed on
the previous shift). Integrity includes recognizing when one's opinions conflict with those of others and
finding a mutually satisfying solution. Confidence is demonstrated in one's presentation and belief in
one's knowledge and abilities. Perseverance helps the critical thinker to find effective solutions to client
care problems, especially when they have been previously unresolved.

A client tells the nurse, "I'm not happy with the way the patient care technician did my bath. He just
seemed to be in a hurry and did not wash my back like I asked." The nurse decides to go talk with the
technician to learn his side of the story as well. This is an example of:

A. Fairness

B. Curiosity

C. Risk taking

D. Responsibility

A. Fairness

Fairness involves analyzing all viewpoints to understand the situation completely before making a
decision. Curiosity gives the critical thinker the motivation to continue to ask questions and learn more.
Risk taking involves trying different ways to solve problems.

The surgical unit has initiated the use of a pain rating scale to assess the severity of clients' pain during
their postoperative recovery. The nurse assigned to a client can look at the pain flow sheet to see the
client's pain scores over the last 24 hours. Use of the pain scale is an example of adherence to which
intellectual standard?

D. Consistency

Using the same pain scale for all clients and ratings promotes consistency—each nurse has the same
measurement scale to compare assessments. Relevance refers to how applicable the assessment is. An
assessment has depth when it deals with less obvious issues. Specificity refers to the ability of the
assessment to provide information about the particular problem of interest.

During the day the nurse spends time instructing a client in how to self-administer insulin. After
discussing the technique and demonstrating an injection, the nurse asks the client to try it. After the
client makes two attempts it is clear that the client does not understand how to prepare the correct
dose. The nurse discusses the situation with the charge nurse and asks for suggestions. This is an
example of:

A. Reflection

B. Risk taking

C. Problem solving

D. Client assessment

C. Problem Solving

This is an example of problem solving because the nurse is taking a problem to a supervisor for help in
finding a different approach. Reflection is the process of purposefully thinking back and recalling a
situation to discover its purpose or meaning. Risk taking involves trying a different approach. Client
assessment is the first step in the process of instruction.

A nurse uses an institution's procedure manual to confirm how to insert a Foley catheter. The level of
critical thinking the nurse is using is:

A. Commitment

B. Scientific method

C. Basic critical thinking

D. Complex critical thinking

C. Basic critical thinking


At the basic level of critical thinking, a learner trusts the experts and follows a procedure step by step.
Complex critical thinkers separate themselves from authorities and analyze and examine choices more
independently. Commitment is the third level of critical thinking in which the person anticipates the
need to make choices without assistance from others. The scientific method is a process of problem
solving.

A nurse refers to a client's postsurgical written plan of care, noting that the client has a drainage device
collecting wound drainage. The surgeon is to be notified when drainage in the device exceeds 100 ml for
the day. The nurse carefully notes the amount of drainage currently in the device. This is an example of:

A. Planning

B. Evaluation

C. Assessment

D. Intervention

C. Assessment

Assessment is the process of observing and collecting data. Planning is the step in which the diagnosis is
analyzed for problem resolution. Intervention consists of the steps actually taken after planning.
Evaluation measures the effectiveness of the plan.

The nurse asks a client how she feels about impending surgery for breast cancer. Before initiating the
discussion the nurse reviewed information about loss and grief in addition to therapeutic
communication principles. The critical thinking component involved in the nurse's review of the
literature is:

A) Experience

B) Problem solving

C) Knowledge application

D) Clinical decision making

C. Knowledge application

The nurse sought appropriate information to be able to communicate more knowledgeably with the
client. Experience is acquired through clinical learning situations. Problem solving is a series of steps to
resolve a problem. Clinical decision making is a process in which critical thinking steps are followed for
problem resolution.
Which of the following is the most accurate information to give a nurse during change-of-shift
reporting?

A) Client refuses to take medications.

B) Client reports sharp pain in left anterior knee.

C) Client encouraged to consume more fluids.

D) Client expressed concern about pending surgery.

B. Client reports sharp pain in elft anterior knee

The information in option 2 represents objective data that the nurse can use as part of baseline
information. "Encouraged" and "more" are vague terms. "Concern" is also vague; relating the exact
concern would be more accurate. Option 1 may be true, but accurate data would also report why the
client refused medication.

On entering a client's room during change-of-shift rounds, the nurse notices that the client and spouse
have their backs turned to each other, and both have their arms folded across their chests. The best
action for the nurse to take at this time is to:

A) Introduce himself or herself and begin discharge teaching.

B) Proceed with the tasks the nurse was intending to perform.

C) Say nothing and leave quickly, closing the door behind.

D) Ask the client and spouse if they need some time alone right now.

D. Ask the client and spouse if they need smoe time alone right now.

The situation suggests that the nurse entered during a stressful time. Offering privacy would be
appropriate. Because the situation indicates tension between the couple, this is not the time to initiate
teaching.

The nurse is assessing the urinary history of a middle-aged married woman. The nurse asks her if she
gets up at night. She replies, "Yes." What other question should the nurse ask?

A) "How many times do you get up at night?"

B) "How long have you been getting up at night?"

C) "Why do you get up at night?"

D) "How easily do you go back to sleep after you get up?"


C. "Why do you get up at night?"

Perhaps it is the client's husband who is getting up in the middle of the night because of a prostate
problem, and this is why she is awakened. The nurse should not assume nocturia without further
assessment questions.

Critical thinking and the nursing process have which of the following in common? Both:

Are important to use in nursing practice

Use an ordered series of steps

Are patient-specific processes

Were developed specifically for nursing

Question 1 Explanation:

Nurses make many decisions: some require using the nursing process, whereas others are not client
related but require critical thinking. The nursing process has specific steps; critical thinking does not.
Neither is linear. Critical thinking applies to any discipline.

Question 2 WRONG

In which step of the nursing process does the nurse analyze data and identify client problems?

Assessment

Diagnosis

Planning outcomes

Evaluation

Question 2 Explanation:

In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase.
In the diagnosis phase, the nurse identifies the client’s health status. In the planning outcomes phase,
the nurse formulates goals and outcomes. In the evaluation phase, which occurs after implementing
interventions, the nurse gathers data about the client’s responses to nursing care to determine whether
client outcomes were met.

Question 3 WRONG

In which phase of the nursing process does the nurse decide whether her actions have successfully
treated the client’s health problem?

Assessment

Diagnosis

Planning outcomes
Evaluation

Question 3 Explanation:

In the assessment phase, the nurse gathers data from many sources for analysis in the diagnosis phase.
In the diagnosis phase, the nurse identifies the client’s health status. In the planning outcomes phase,
the nurse and client decide on goals they want to achieve. In the intervention planning phase, the nurse
identifies specific interventions to help achieve the identified goal. During the implementation phase,
the nurse carries out the interventions or delegates them to other health care team members. During
the evaluation phase, the nurse judges whether her actions have been successful in treating or
preventing the identified client health problem.

Question 4 WRONG

What is the most basic reason that self-knowledge is important for nurses? Because it helps the nurse
to:

Identify personal biases that may affect his thinking and actions

Identify the most effective interventions for a patient

Communicate more efficiently with colleagues, patients, and families

Learn and remember new procedures and techniques

Question 4 Explanation:

The most basic reason is that self-knowledge directly affects the nurse’s thinking and the actions he
chooses. Indirectly, thinking is involved in identifying effective interventions, communicating, and
learning procedures. However, because identifying personal biases affects all the other nursing actions,
it is the most basic reason.

Question 5 WRONG

Arrange the steps of the nursing process in the sequence in which they generally occur. A. Assessment B.
Evaluation C. Planning outcomes D. Planning interventions E. Diagnosis

E, B, A, D, C

A, B, C, D, E

A, E, C, D, B

D, A, B, E, C

Question 5 Explanation:

Logically, the steps are assessment, diagnosis, planning outcomes, planning interventions, and
evaluation. Keep in mind that steps are not always performed in this order, depending on the patient’s
needs, and that steps overlap.

Question 6 WRONG
How are critical thinking skills and critical thinking attitudes similar? Both are:

Influences on the nurse’s problem solving and decision making

Like feelings rather than cognitive activities

Cognitive activities rather than feelings

Applicable in all aspects of a person’s life

Question 6 Explanation:

Cognitive skills are used in complex thinking processes, such as problem solving and decision making.
Critical thinking attitudes determine how a person uses her cognitive skills. Critical thinking attitudes are
traits of the mind, such as independent thinking, intellectual curiosity, intellectual humility, and fair-
mindedness, to name a few. Critical thinking skills refer to the cognitive activities used in complex
thinking processes. A few examples of these skills involve recognizing the need for more information,
recognizing gaps in one’s own knowledge, and separating relevant from irrelevant data. Critical thinking,
which consists of intellectual skills and attitudes, can be used in all aspects of life.

Question 7 WRONG

The nurse is preparing to admit a patient from the emergency department. The transferring nurse
reports that the patient with chronic lung disease has a 30+ year history of tobacco use. The nurse used
to smoke a pack of cigarettes a day at one time and worked very hard to quit smoking. She immediately
thinks to herself, “I know I tend to feel negatively about people who use tobacco, especially when they
have a serious lung condition; I figure if I can stop smoking, they should be able to. I must remember
how physically and psychologically difficult that is, and be very careful not to let be judgmental of this
patient.” This best illustrates:

Theoretical knowledge

Self-knowledge

Using reliable resources

Use of the nursing process

Question 7 Explanation:

Personal knowledge is self-understanding—awareness of one’s beliefs, values, biases, and so on. That
best describes the nurse’s awareness that her bias can affect her patient care. Theoretical knowledge
consists of information, facts, principles, and theories in nursing and related disciplines; it consists of
research findings and rationally constructed explanations of phenomena. Using reliable resources is a
critical thinking skill. The nursing process is a problem-solving process consisting of the steps of
assessing, diagnosing, planning outcomes, planning interventions, implementing, and evaluating. The
nurse has not yet met this patient, so she could not have begun the nursing process.

Question 8 CORRECT

Which organization’s standards require that all patients be assessed specifically for pain?
American Nurses Association (ANA)

State nurse practice acts

National Council of State Boards of Nursing (NCSBN)

The Joint Commission

Question 8 Explanation:

The Joint Commission has developed assessment standards, including that all clients be assessed for
pain. The ANA has developed standards for clinical practice, including those for assessment, but not
specifically for pain. State nurse practice acts regulate nursing practice in individual states. The NCSBN
asserts that the scope of nursing includes a comprehensive assessment but does not specifically include
pain.

Question 9 WRONG

Which of the following is an example of data that should be validated?

The urinalysis report indicates there are white blood cells in the urine.

The client states she feels feverish; you measure the oral temperature at 98°F.

The client has clear breath sounds; you count a respiratory rate of 18.

The chest x-ray report indicates the client has pneumonia in the right lower lobe.

Question 9 Explanation:

Validation should be done when subjective and objective data do not make sense. For instance, it is
inconsistent data when the patient feels feverish and you obtain a normal temperature. The other
distractors do not offer conflicting data. Validation is not usually necessary for laboratory test results.

Question 10 WRONG

Which of the following is an example of appropriate behavior when conducting a client interview?

Recording all the information on the agency-approved form during the interview

Asking the client, “Why did you think it was necessary to seek health care at this time?”

Using precise medical terminology when asking the client questions

Sitting, facing the client in a chair at the client’s bedside, using active listening

Question 10 Explanation:

Active listening should be used during an interview. The nurse should face the patient, have relaxed
posture, and keep eye contact. Asking “why” may make the client defensive. Note-taking interferes with
eye contact. The client may not understand medical terminology or health care jargon.

Question 11 WRONG
The nurse wishes to identify nursing diagnoses for a patient. She can best do this by using a data
collection form organized according to: Select all that apply.

A body systems model

A head-to-toe framework

Maslow’s hierarchy of needs

Gordon’s functional health patterns

Question 11 Explanation:

Nursing models produce a holistic database that is useful in identifying nursing rather than medical
diagnoses. Body systems and head-to-toe are not nursing models, and they are not holistic; they focus
on identifying physiological needs or disease. Maslow’s hierarchy is not a nursing model, but it is holistic,
so it is acceptable for identifying nursing diagnoses. Gordon’s functional health patterns are a nursing
model.

Question 12 CORRECT

The nurse is recording assessment data. She writes, “The patient seems worried about his surgery. Other
than that, he had a good night.” Which errors did the nurse make? Select all that apply.

Used a vague generality

Did not use the patient’s exact words

Used a “waffle” word (e.g., appears)

Recorded an inference rather than a cue

Question 12 Explanation:

The nurse recorded a vague generality: “he has had a good night.” The nurse did not use the patient’s
exact words, but she did not quote the patient at all, so that is not one of her errors. The nurse used the
“waffle” word, “seems” worried instead of documenting what the patient said or did to lead her to that
conclusion. The nurse recorded these inferences: worried and had a good night.

Question 13 WRONG

A patient is admitted with shortness of breath, so the nurse immediately listens to his breath sounds.
Which type of assessment is the nurse performing?

Ongoing assessment

Comprehensive physical assessment

Focused physical assessment

Psychosocial assessment

Question 13 Explanation:
The nurse is performing a focused physical assessment, which is done to obtain data about an identified
problem, in this case shortness of breath. An ongoing assessment is performed as needed, after the
initial data are collected, preferably with each patient contact. A comprehensive physical assessment
includes an interview and a complete examination of each body system. A psychosocial assessment
examines both psychological and social factors affecting the patient. The nurse conducting a
psychosocial assessment would gather information about stressors, lifestyle, emotional health, social
influences, coping patterns, communication, and personal responses to health and illness, to name a
few aspects.

Question 14 WRONG

The nurse is assessing vital signs for a patient just admitted to the hospital. Ideally, and if there are no
contraindications, how should the nurse position the patient for this portion of the admission
assessment?

Sitting upright

Lying flat on the back with knees flexed

Lying flat on the back with arms and legs fully extended

Side-lying with the knees flexed

Question 14 Explanation:

If the patient is able, the nurse should have the patient sit upright to obtain vital signs in order to allow
the nurse to easily access the anterior and posterior chest for auscultation of heart and breath sounds. It
allows for full lung expansion and is the preferred position for measuring blood pressure. Additionally,
patients might be more comfortable and feel less vulnerable when sitting upright (rather than lying
down on the back) and can have direct eye contact with the examiner. However, other positions can be
suitable when the patient’s physical condition restricts the comfort or ability of the patient to sit
upright.

Question 15 WRONG

For all body systems except the abdomen, what is the preferred order for the nurse to perform the
following examination techniques? A. Palpation B. Auscultation C. Inspection D. Percussion

D, B, A, C

C, A, D, B

B, C, D, A

A, B, C, D

Question 15 Explanation:

Inspection begins immediately as the nurse meets the patient, as she observes the patient’s appearance
and behavior. Observational data are not intrusive to the patient. When performing assessment
techniques involving physical touch, the behavior, posture, demeanor, and responses might be altered.
Palpation, percussion, and auscultation should be performed in that order, except when performing an
abdominal assessment. During abdominal assessment, auscultation should be performed before
palpation and percussion to prevent altering bowel sounds.

Question 16 CORRECT

The nurse is assessing a patient admitted to the hospital with rectal bleeding. The patient had a hip
replacement 2 weeks ago. Which position should the nurse avoid when examining this patient’s rectal
area?

Sims’

Supine

Dorsal recumbent

Semi-Fowler’s

Question 16 Explanation:

Sims’ position is typically used to examine the rectal area. However, the position should be avoided if
the patient has undergone hip replacement surgery The patient with a hip replacement can assume the
supine, dorsal recumbent, or semi-Fowler’s positions without causing harm to the joint. Supine position
is lying on the back facing upward. The patient in dorsal recumbent is on his back with knees flexed and
soles of feet flat on the bed. In semi-Fowler’s position, the patient is supine with the head of the bed
elevated and legs slightly elevated.

Question 17 WRONG

How should the nurse modify the examination for a 7-year-old child?

Ask the parents to leave the room before the examination.

Demonstrate equipment before using it.

Allow the child to help with the examination.

Perform invasive procedures (e.g., otoscopic) last.

Question 17 Explanation:

The nurse should modify his examination by demonstrating equipment before using it to examine a
school-age child. The nurse should make sure parents are not present during the physical examination of
an adolescent, but they usually help younger children feel more secure. The nurse should allow a
preschooler to help with the examination when possible, but not usually a school-age child. Toddlers are
often fearful of invasive procedures, so those should be performed last in this age group. It is best to
perform invasive procedures last for all age groups; therefore, this does not represent a modification.

Question 18 WRONG

The nurse must examine a patient who is weak and unable to sit unaided or to get out of bed. How
should she position the patient to begin and perform most of the physical examination?
Dorsal recumbent

Semi-Fowler’s

Lithotomy

Sims’

Question 18 Explanation:

If a patient is unable to sit up, the nurse should place him lying flat on his back, with the head of the bed
elevated. Dorsal recumbent position is used for abdominal assessment if the patient has abdominal or
pelvic pain. The patient in dorsal recumbent is on his back with knees flexed and soles of feet flat on the
bed. Lithotomy position is used for female pelvic examination. It is similar to dorsal recumbent position,
except that the patient’s legs are well separated and thighs are acutely flexed. Feet are usually placed in
stirrups. Fold sheet or bath blanket crosswise over thighs and legs so that genital area is easily exposed.
Keep patient covered as much as possible. The patient in Sim’s position is on left side with right knee
flexed against abdomen and left knee slightly flexed. Left arm is behind body; right arm is placed
comfortably. Sims’ position is used to examine the rectal area. In semi-Fowler’s position, the patient is
supine with the head of the bed elevated and legs slightly elevated.

Question 19 WRONG

The nurse should use the diaphragm of the stethoscope to auscultate which of the following?

Heart murmurs

Jugular venous hums

Bowel sounds

Carotid bruits

Question 19 Explanation:

The bell of the stethoscope should be used to hear low-pitched sounds, such as murmurs, bruits, and
jugular hums. The diaphragm should be used to hear high-pitched sounds that normally occur in the
heart, lungs, and abdomen.

Question 20 CORRECT

The nurse calculates a body mass index (BMI) of 18 for a young adult woman who comes to the
physician’s office for a college physical. This patient is considered:

Obese

Overweight

Average

Underweight

Question 20 Explanation:
For adults, BMI should range between 20 and 25; BMI less than 20 is considered underweight; BMI 25 to
29.9 is overweight; and BMI greater than 30 is considered obese.