ch 38 Flashcards
A student nurse is studying clinical judgment theories and is working with Tanner’s Model of Clinical Judgment. How can the student nurse best generalize this model?
a. A reflective process where the nurse notices, interprets, responds, and reflects in
action
b. One conceptual mechanism for critiquing ideas and establishing goal-oriented
care
c. Researching best practice literature to create care pathways for certain
populations
d. Assessing, diagnosing, implementing, and evaluating the nursing care plans
ANS: A
Looking across theories and definitions of clinical judgment, they all have in common the ability to reflect on data and choose actions. Reflection also considers evaluating the result of the actions to determine whether they were effective. Although critiquing ideas and establishing goal-oriented care could be considered part of a generalized statement of critical thinking, this is not broad enough without the reflection and evaluation. Clinical judgment would most likely be used to create care paths derived from the evidence; however, this is not the cornerstone of the Tanner Model. Clinical judgment is used when engaging in the nursing process, but this is too narrow in focus to capture the essence of critical thinking definitions and theories. Critical thinking is not synonymous with the nursing process.
The nurse is implementing a plan of care for a patient newly diagnosed with type 2 diabetes mellitus. The plan includes educating the patient about diet choices. The patient states that they enjoy exercising and understand the need to diet; however, they can’t see living without chocolate on a daily basis. Using the principles of responding in the Model of Clinical Judgment, how would the nurse proceed with the teaching?
a. The nurse explains to the patient that chocolate has a high glycemic index. The nurse then focuses on foods that have low glycemic indexes and provides a list for the patient to choose from.
b. The nurse explains that the patient may eat whatever they would like as long as the patient’s glucose reading and A1c remain stable.
c. The nurse derives a new nursing diagnosis of Knowledge Deficit and readjusts the plan of care to include additional sessions with the registered dietician.
d. The nurse examines the patient’s daily glucose log and incorporates the snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week.
ANS: D
Responding entails adjusting the plan of care to the particular patient issue through one or more nursing interventions. In this case, the nurse is working with the patient’s wishes, knowing that the patient will most likely cheat. The patient will be allowed to “cheat.” The plan will be evaluated to be sure the snack does not elevate the glucose excessively and be readjusted if warranted. While it is true that most chocolate has a high glycemic index, providing a list of foods that do not include the one thing the patient enjoys will most likely lead to nonadherence to the diet. Advising the patient that they can have whatever they want to eat may lead to further dietary indiscretions and cause side effects such as obesity or high glucose readings. Knowledge Deficit is an inaccurate diagnosis for this patient as evidenced by the patient stating they understand the need to exercise and the need to diet.
A new graduate nurse is working with an experienced nurse to chart assessment findings. The new nurse notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced nurse asks the new nurse what may be going on here. What is the best explanation for this statement?
a. Data on the chart can sometimes be documented in a biased manner.
b. Data on the chart changes as the patient’s condition changes.
c. Data on the chart is usually accurate and can be verified from the patient.
d. Reading the chart is not a wise use of time as this can be time consuming and
tedious.
ANS: A
It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record. Data do indeed change (and need to be charted) as the patient’s condition changes, but this would not be the best answer to this question. Assessment data may at times be difficult to obtain, but that would not occur often enough to warrant a warning about the difficulty in charting it. Also, obtaining data is clearly a different activity from charting it. Charting can be time consuming and tedious, but this is not the most complete answer to this question.
A home care nurse receives a physician order for a medication that the patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient’s condition, questions its appropriateness, and examines alternative treatments. What is the nurse’s best action?
a. Call the physician, explain rationale, and suggest a different medication.
b. Consult an experienced nurse on whether there are other similar treatments.
c. Hold the drug until the physician returns to the unit and can be questioned.
d. Question other staff as to the physician’s acceptance of nursing input.
ANS: A
Determining how best to proceed on behalf of a patient’s best health outcomes care may require clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities have been examined. A home care nurse who is using good clinical judgment techniques should have confidence in their decision and may not have another nurse available as this is an autonomous setting. Holding the drug might jeopardize the patient’s health, so this is not the best solution. The nurse working at this level of critical thinking makes choices based on careful examination of situations and alternatives; whether or not the physician is open to nursing input is not relevant.
A patient has been admitted for a skin graft following third degree burns to the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes. When should the nurse initiate the educational plan?
a. After the operation and the patient is awake
b. On admission, along with the initial assessment
c. The day before the patient is to be discharged
d. When narcotics are no longer needed routinely
ANS: B
Initial discharge planning begins upon admission. After the operation has been completed is too late to begin the discharge planning process. The day before discharge is too late for the nurse to gather all pertinent information and begin teaching and coordinating resources. After a complicated operation, the patient may well be discharged on narcotic analgesics. Waiting for the patient to not need them anymore might mean the patient gets discharged without teaching being done.
A nurse has designed an individualized nursing care plan for a patient, but the patient is not meeting goals. Further assessment reveals that the patient is not following through on many items. Which action by the nurse would be best for determining the cause of the problem?
a. Assess whether the actions were too hard for the patient.
b. Determine whether the patient agrees with the care plan.
c. Question the patient’s reasons for not following through.
d. Reevaluate data to ensure the diagnoses are sound.
ANS: B
Having patient and/or family provide input to the care plan is vital in order to gain support for the plan of action. The actions may have been too difficult for the patient, but this is a very narrow item to focus on. The nurse might want to find out the rationale for the patient not following through, but instead of directly questioning the patient, which can sound accusatory, it would be best to offer some possible motives. Reevaluation should be an ongoing process, but the more likely cause of the patient’s failure to follow through is that the patient did not participate in making the plan of care.
A new nurse appears to be second-guessing herself and is constantly calling on the other nurses to double-check their plan of care or rehearse what they will say to the doctor before she call on the patient’s behalf. This seems to be annoying some of the nurse’s coworkers. What is the nurse manager’s best response?
a. Explain to coworkers that this is a characteristic of critical thinking and is
important for the new nurse to improve reasoning skills.
b. Agree with the staff and have someone follow and work more closely with a
preceptor.
c. Have a talk with the nurse and suggest asking fewer questions.
d. Tell the staff that all new nurses go through this phase, and ignore their behavior.
ANS: A
Reflection-on-action is critical for development of knowledge and improvement in reasoning. It is where learning from practice is incorporated into experience. Inquisitiveness is a characteristic of critical thinking and reflects a desire to learn ev en when the knowledge may not appear readily useful. The manager should promote this. Suggesting the nurse work more closely with a preceptor implies that the manager thinks the nurse needs to learn more and increase confidence. In reality, this nurse is demonstrating a characteristic of critical thinking. Suggesting that the nurse ask fewer questions would hamper the development of the nurse as a critical thinker. All new nurses do go through a phase of asking more questions at one time, but dismissing the nurse’s behavior with this explanation is simplistic and will discourage critical thinking.
A nurse has committed a serious medication error and has reported the error to the hospital’s adverse medication error hotline as well as to the unit manager. The manager is a firm believer in developing critical thinking skills. From this standpoint, what action by the manager would best nurture this ability in the nurse who made the error?
a. Have the nurse present an in-service related to the cause of the error.
b. Instruct the nurse to write a paper on how to avoid this type of error.
c. Let the nurse work with more experienced nurses when giving medications.
d. Send the nurse to refresher courses on medication administration.
ANS: A
Nurturing critical thinking skills is done in part by turning errors into learning opportunities. If the nurse presents an in-service on the cause and prevention of the type of error committed, not only will the nurse learn something but many others nurses on the unit will learn from it to. This is the best example of developing critical thinking skills. This option would allow the nurse to learn from the mistake, which is a method of developing critical thinking skills, but the paper would benefit only the nurse, so this option is not the best choice. Letting the nurse work with more experienced nurses might be a good option in a very limited setting, for example, if the nurse is relatively new and the manager discovers a deficiency in the nurse’s orientation or training on giving medications in that system. Otherwise, this option would not really be beneficial. Sending the nurse to refresher courses might be a solution, but it is directed at the nurse’s learning, not critical thinking. The nurse might feel resentful at having to attend such classes, but even if they were helpful, only this one nurse is learning. Going to generic classes also does not address the specific reason this error occurred, and thus might be irrelevant. Critical thinking and learning can be enhanced by a presentation to the staff on the causes of the error.
A nurse is caring for a patient in a long-term care facility who has not been sleeping well. She notes that the patient is new to the facility, has been refusing therapy, and is also not eating well. The nurse interprets this to mean that the patient has been having trouble adjusting. The nurse decides to meet with the patient’s care team. The team decides to assess the patient’s willingness to participate in group recreational activities. The patient agrees to participate. After 1 week, the nurse reevaluates the plan of care and notes that the patient has been sleeping much better. Which of the following terms best describe processes used in the nurse’s plan? (Select all that apply.)
a. Clinical judgment
b. Evidence-based practice
c. The nursing process
d. Collaborative care planning
e. Positive reward process
ANS: A, C, D
Clinical judgment is a reflective process by which the nurse notices, interprets, responds, and reflects in action. The nursing process is a process by which the nurse assesses, diagnoses, implements, and evaluates the nursing care plan. Consulting and gaining input from the healthcare team is collaborative care planning. Evidence-based practice refers to using interventions found in research studies. The positive reward process is not a term used in care planning.
