Critical Thinking and the Nursing Process

Every question here, with the answer

1. At the end of a cardiology clinic visit, you review the patient's blood pressure measurements from the past three visits. They have gradually risen to above-normal values. Which assessment entry best supports an individualized plan of care?

   1. Blood pressure is above normal today; another visit is needed before the existing measurements can be assessed for a pattern.
   2. Blood pressure is above normal today; assessment is based on the current reading without comparison to previous visits.
   3. Blood pressure readings have increased; interpretation of these findings will be deferred until a medical diagnosis is established.
   4. Blood pressure has gradually risen across three visits to above-normal values; this unexpected trend will inform the care plan.

   Answer: Blood pressure has gradually risen across three visits to above-normal values; this unexpected trend will inform the care plan.

   The assessment should recognize the unexpected pattern across visits and use it to guide individualized care. Considering only today's reading misses the trend, while waiting for another visit or a medical diagnosis unnecessarily postpones analysis of data already available.

2. At 0800, you begin an admission assessment. The patient and a family caregiver are available, and you can access the medical record. Which approaches should you use to build the assessment documentation? Select all that apply.

   1. Gather relevant information from the patient's medical record.
   2. Gather relevant information from the family caregiver.
   3. Use only the patient and medical record as sources, excluding caregiver information from the assessment.
   4. Include information reported by the patient alongside physical assessment findings.
   5. Limit the assessment to physical findings, saving the patient's reported concerns for a later care-plan review.

   Answer: Gather relevant information from the patient's medical record., Gather relevant information from the family caregiver., Include information reported by the patient alongside physical assessment findings.

   The section identifies the patient, medical record, family members or caregivers, and physical findings as assessment sources. Restricting the entry to physical findings leaves out subjective information, and excluding the caregiver omits another source explicitly included in the assessment process.

3. At 1400, a patient with previously diagnosed hypertension arrives in the emergency department reporting 10/10 chest pain. You are updating the prioritized problems in the care plan. Which entry best reflects the patient's current situation?

   1. Retain the previous hypertension-focused priorities until a new medical diagnosis is confirmed.
   2. List hypertension and the chest-pain concern without ranking them until more assessment data are available.
   3. Keep hypertension as the first priority because it is an established diagnosis; add chest pain below it.
   4. Prioritize the potential myocardial infarction over treatment of the underlying hypertension.

   Answer: Prioritize the potential myocardial infarction over treatment of the underlying hypertension.

   The patient's current presentation changes the priorities: the potential myocardial infarction takes precedence over the underlying hypertension. Keeping the established diagnosis first, leaving the problems unranked, or waiting for confirmation fails to apply the section's situation-based prioritization.

4. Near the end of your shift, you evaluate a patient after prescribed pain medication and find that the pain has not been relieved. You document the patient's response. Which care-plan updates are supported by the section? Select all that apply.

   1. Document persistent pain but leave the interventions unchanged for the next shift to evaluate.
   2. Revise the plan to include advocating for a change in the medication order.
   3. Use completion of the prescribed medication administration as the evaluation of the pain outcome.
   4. Revise the plan to include a nonpharmacological approach, such as position change or distraction.
   5. Update the nursing diagnosis to reflect persistent pain without revisiting the plan or interventions.

   Answer: Revise the plan to include advocating for a change in the medication order., Revise the plan to include a nonpharmacological approach, such as position change or distraction.

   When prescribed medication does not relieve pain, the section directs the nurse to revisit the plan and add interventions, including advocating for an order change or using nonpharmacological methods. Completing an intervention is not evidence that the outcome was achieved. Recording persistent pain, deferring changes, or revising only the diagnosis does not make the needed adjustment to the pain-management plan.

5. At 0900 in a cardiology clinic, you review the last three visit records and see the patient’s blood pressure has gradually risen to above normal values. You are completing the assessment portion of the nursing process. What is the best way to handle this finding?

   1. Identify the rising blood pressure as an unexpected pattern and use it to guide the nursing diagnosis and individualized plan of care.
   2. Treat the current blood pressure as the only usable finding because prior visits are not part of this assessment.
   3. Record the trend as routine and expected because gradual changes do not affect the nursing process.
   4. Skip assessment analysis and enter hypertension as the nursing diagnosis.

   Answer: Identify the rising blood pressure as an unexpected pattern and use it to guide the nursing diagnosis and individualized plan of care.

   Assessment is not just data collection; the nurse analyzes relevant data, notices unexpected findings, and looks for patterns. The other options ignore the trend, label it routine, or jump to a diagnosis without assessment analysis.

6. At 1100, after assessment data are reviewed, a patient receives a medical diagnosis of hypertension. You need to identify problem-based nursing diagnoses for the plan of care. Which entry best fits the nursing process described in the section?

   1. Open the blocked vessel to limit cardiac tissue damage.
   2. Hypertension.
   3. Gradual rise in blood pressure measurements over three clinic visits.
   4. Decreased cardiac output; risk for impaired cerebral tissue perfusion; activity intolerance.

   Answer: Decreased cardiac output; risk for impaired cerebral tissue perfusion; activity intolerance.

   Nursing diagnoses describe patient problems related to the medical condition and are broader than simply naming the condition. Hypertension is the medical diagnosis, the blood pressure trend is assessment data, and opening the blocked vessel is a planned outcome from the chest pain example.

7. At 1500, two nurses are reconciling a shared care plan before handoff. They want the plan to support consistent care rather than create duplicate work. Which uses of the nursing process match the section’s stated benefits? Select all that apply.

   1. Use the plan to avoid modifying care after evaluation.
   2. Use the plan to decrease omissions and duplications in care.
   3. Use the plan as a guide so all involved staff provide consistent and responsive care.
   4. Use the plan to keep each discipline working separately on the patient’s problems.
   5. Use the plan to reduce continuity between providers and institutions.

   Answer: Use the plan to decrease omissions and duplications in care., Use the plan as a guide so all involved staff provide consistent and responsive care.

   The section identifies fewer omissions and duplications and a guide for staff to provide consistent, responsive care as benefits. The other options contradict the described benefits: the process encourages collaboration, supports modification, and improves continuity.

8. At 1800, you evaluate a patient after giving the prescribed pain medication, and the patient’s pain is not relieved. According to the evaluation step, what should you do next in the plan of care?

   1. Replace the nursing diagnosis with the medical condition causing the pain.
   2. Continue the same plan unchanged because evaluation happens only after all diagnoses are resolved.
   3. Return to the plan and modify it with additional interventions, such as advocating for a medication order change or using nonpharmacological methods.
   4. Document that the expected outcome was achieved because the ordered medication was administered.

   Answer: Return to the plan and modify it with additional interventions, such as advocating for a medication order change or using nonpharmacological methods.

   Evaluation determines whether actions were effective; if the outcome is not achieved, the care plan may need modification. The other options confuse implementation with success, prevent needed revision, or substitute a medical diagnosis for nursing problem-solving.

9. At 1030 on a medical-surgical unit, a patient develops facial droop and dysarthria and cannot move their arm. Which actions from the section’s clinical judgment example should the nurse take? Select all that apply.

   1. Document only hygiene care and bed linen changes because those are the nurse’s main role.
   2. Wait to act until a physician gives orders, because nursing decisions are task-oriented.
   3. Treat the findings as expected data and continue the current plan without change.
   4. Notify the stroke emergency responders according to the institution’s policy.
   5. Perform a neurological assessment.

   Answer: Notify the stroke emergency responders according to the institution’s policy., Perform a neurological assessment.

   The example states that the nurse uses clinical judgment to assess neurologic status and notify stroke responders per policy. Waiting passively, treating new deficits as expected, or reducing the nurse’s role to basic tasks contradicts the section’s description of contemporary nursing judgment.