NCLEX questions for Nursing Process and Standards of Practice Flashcards
The patient asks the nurse, “I’ve heard the student nurses talk about the nursing process. Why is there so much emphasis on using the nursing process?” The response that explains the need for nurses to understand and use the nursing process is:
a. “Do you think you have a better method we might use?”
b. “The nursing process is a systematic problem-solving method encompassing all components necessary to care for patients.”
c. “Using the nursing process is a way of legitimizing our profession and placing us on an equal footing with the pure sciences.”
d. “The nursing process is a unidimensional, static, linear approach used to guide nurses as they make clinical judgments.”
B
This response best explains the importance of the nursing process by description and relationship to patient care. Suggesting that the patient may have a better method is challenging and does not address the question posed by the patient. Providing legitimacy to the profession is a very limited explanation for use of the nursing process. The nursing process is not one-dimensional, static, or linear
When preparing to conduct a nursing history and assessment on a patient transferred from the emergency department (ED) whose family believes the patient to be a questionable historian due to cognitive impairment, the nurse initially begins the interview by:
a. Reviewing the ED chart
b. Contacting the admitting physician
c. Directing the questions to the family members
d. Establishing a line of communication with the patient
D
The nurse should begin establishing the nurse–patient relationship by initially directing the questions to the patient. The nurse can confirm information and/or obtain supplementary information from the sources identified by the other options
The nurse shows the ability to effectively state a nursing diagnosis reflective of the implications of depression on a patient’s life processes when stating in the patient’s plan of care that:
a. Patient outcomes were partially attained. Implementation of present plan to continue.
b. Patient will initiate and support conversation with nurse therapist by (date 3 weeks in future).
c. Oral medication for anxiety should be administered when depression is assessed to be at the moderate level.
d. Impaired verbal communication r/t impoverished thoughts secondary to depression as evidenced by monosyllabic responses.
D
This statement contains the various components of a nursing diagnosis while expressing the existence of an altered life process. The remaining options reflect other steps, such as evaluation and intervention planning.
When engaging in outcomes identification, the nurse:
a. Interviews and collects patient-focused data
b. Re-assesses the patient’s physical and emotional status evaluation
c. Reviews the patient’s existing problems and projects the results of the nursing care
d. Considers the patient’s presenting symptoms and identifies nursing-related problems
C
Outcomes are projections of expected influence that nursing interventions will have on the patient. Interviewing and collecting data is involved in the assessment process, re-assessing is involved in the evaluation process, and identifying related nursing problems is involved in determining appropriate nursing diagnoses.
While discussing assessment of suicidal patients, a novice nurse mentions, “I was taught to always base my care on concrete, evidence-based scientific reasoning and never to rely on intuition.” Which response by the experienced nurse shows understanding of intuitive reasoning?
a. “That’s wise, because intuition went out of favor with the scientific revolution.”
b. “Critical thinking and intuition are at opposite poles. Keep relying on your expertise.”
c. “It’s possible that intuition about suicidality is generated by transfer of feelings from the patient to the nurse.”
d. “It’s been determined that intuition is nothing more that extrasensory perception, so some folks have it, and some don’t.”
C
A “strong hunch” or a “gut feeling” is an example of intuitive reasoning that is believed to come from the therapeutic relationship’s sharing of feelings between nurse and patient. Most nurses agree that intuition is compatible with scientific reasoning, because both are likely linked to practice and experience. A nurse learns intuitive reasoning through clinical practice rather than from school or books.
A nurse shows effective critical thinking skills directed towards nursing care of a cognitively impaired patient who continues to socially isolate by:
a. Clearly stating that the patient must socially interact once daily
b. Documenting that the patient continues to resist socialization
c. Asking the patient to identify which unit activity they are willing to attend
d. Suggesting that staff take the patient with them when running errands off the unit
D
Critical thinking in this case involves the creation of alternative solutions to a problem that was not resolved by conventional methods. The remaining options, although not inappropriate, do not show critical thinking skills
A depressed patient shares with the nurse that he, “has been thinking about ending it all”. Based on NANDA recommendations, the nurse:
a. Implements suicide precautions for this patient
b. Includes ‘Risk for Self Harm’ to the patient’s care plan
c. Documents regarding the patient’s safety every 15 minutes
d. Reviews the patient’s chart for references to past incidences of hopeless
B
NANDA states that a nurse is able to change any actual diagnosis on the NANDA list to a risk diagnosis if the problem has not occurred yet. The remaining options, although not inappropriate, do not related to NANDA.
The nurse shows an understanding of the appropriate use of nursing outcomes regarding triggers for a patient diagnosed with chronic alcohol abuse when stating:
a. “Can you work on identifying three situations that cause you to abuse alcohol?”
b. ”I’ll help you to identify three triggers for your drinking during today’s session.”
c. ”I’m pleased you’ve identified three situations that trigger your abuse of alcohol.”
d. “Do you think you will be able to avoid the three triggers that cause you to drink?”
C
Outcomes sometimes referred to as behavioral goals are used to describe and evaluate the effectiveness of nursing interventions. The correct option shows that the patient was successful at accomplishing an outcome inferring the nursing interventions were successful. The remaining options do not indicate an evaluation of success or failure
When a patient experiencing acute depression asks what the difference is between a medical and a nursing diagnosis, the nurse responds best when stating:
a. Actually they are very similar in that they both are concerned with helping you get better and lead a happier life.
b. Medical diagnoses are focused on why you are depressed whereas nursing diagnoses are concerned about making your life less sad.
c. Nursing diagnoses are more directed at caring for you, unlike medical diagnoses that focus on finding the cause for your problem.
d. The medical diagnosis identifies that you are experiencing depression whereas the nursing diagnosis identifies how the depression is affecting you.
D
The medical diagnosis involves identifying a mental or physical problem that results in the symptoms that negatively affect a patient’s life. Although the nurse is knowledgeable about the disorders and their treatments, the nursing diagnosis focuses mainly on the patient’s responses to the disorder and the effects that the disorder has on the patient. The types of diagnoses have different foci that result in different actions and concerns
A nurse best shows an understanding of the role of evidence-based research in achieving therapeutic patient care outcomes when:
a. Subscribing to and reading a monthly psychiatric research nursing journal
b. Working on a committee to revise current facility policies regarding the use of chemical restraints
c. Registering to attend a psychiatric workshop on newly developed psychotropic medication therapies
d. Asking an experienced staff member to review the interventions being proposed for a newly admitted patient
B
Evidence-based practice is based on evidence and scientific principles that have been developed through research. The more closely clinical practice reflects relevant research, the more likely it is that patients will receive the best available care. The option that infers action directed at implementing the research is the one that shows best understanding. Reliance only on experience is not reflective of quality nursing care
When caring for a patient admitted with a diagnosis if bipolar disorder, managed care regulations is the driving force behind the nurse’s use of:
a. NANDA nursing diagnoses
b. Short-term stress management therapy
c. A specialized clinical pathway for such patients
d. Generic instead of brand name medications
C
Managed care regulations have brought about the use of clinical pathways (also called critical pathways or a care maps) which are standardized multidisciplinary planning tools that monitor patient care through projected caregiver interventions and expected patient outcomes with a projected timeline of success. NANDA nursing diagnoses are not related to regulations or payment concerns. The implementation of short-term stress management therapy in an acute care psychiatric environment would not be driven by managed care regulation or payment concerns. The use of generic medications when appropriate is primarily cost driven.
A benefit of the implementation of clinical pathways is evidenced when the patient states:
a. “I know my doctors and nurses really care about me.”
b. “My medication has really helped lessen my symptoms.”
c. “I have hopes that I will be able to lead a productive, healthy life.”
d. “My care team has really helped me manage most of my problems.”
D
Clinical pathways are tools that among other things promote interdisciplinary care thus providing for holistic care of the patient. The remaining options do not involve the additional recognized benefits of clinical pathways that include cost effectiveness and access to patient status reports.
A nurse shows the best understanding of the legal importance of the patient’s chart when stating:
a. “You always document in ink and never erase or use “white out” in the nursing notes.”
b. “It’s a document that shows proof that the patient received care that met the expected standards.”
c. “Patient charts are carefully protected from unlawful access by inappropriate individuals or institutions.”
d. “The patient has a legal right to the information contained in the chart but not the original documentation itself.”
B
The patient’s chart is a legal document that effectively communicates patient outcomes, medications, treatments, responses, and unusual incidents reflecting the healthcare systems attempts at meet the standard of care appropriate for this patient. The other options are not as inclusive in describing the legal status of the chart
The nurse best fulfills the obligation to be accountable for providing care that meets the expected standards of care when:
a. Developing a therapeutic relations with the patient
b. Applying evidence-based nursing practice to the plan of care
c. Providing appropriate discharge planning to meet the patient’s needs
d. Evaluating the effectiveness of interventions through achievement of outcomes
D
Evaluation of the patient’s progress and the nursing activities involved are critical because nurses are accountable for the standards of care in each discipline. Although the other options reflect appropriate and expected nursing interventions, they are not the primary means of assuring that standard of care has been met
The nurse assesses a patient’s judgment by asking:
a. “Why did you run away?”
b. “When did you first start hearing voices?”
c. “What would you do if you smelled smoke in your home?”
d. “Do you believe you hear voices, or do you think it is in your mind?”
C
Judgment is the ability to assess and evaluate situations, make rational decisions, understand consequences of behavior, and take responsibility for actions. Judgment may be assessed by asking a question that has a common-sense answer. The other options ask about motivation, elicits historical information about the illness or seeks information about insight
