Test Bank For Taylor’s Clinical Nursing Skills A Nursing
Process Approach 5th Edition By Pamela Lynn
Steps of the Nursing Process - ANSWER 1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
Assessment - ANSWER noticing/recognizing what is going on with the client
systematic gathering of information related to the physical, mental, socioeconomical
and cultural status of an individual, group of community
Analysis/Diagnosis - ANSWER analyzing cues; interpreting what is going on with
the patient thru reviewing lab work, diagnostic testing, patient hx, complaints and
observations
Planning (outcomes and intervention) - ANSWER prioritize hypotheses and
generate solutions
set goals (behavior I want to see in the patient
Implementation - ANSWER responding to the needs of the patient
taking action
the actual doing
the three D's
Evaluation - ANSWER reflecting on the care given; evaluation actions and
outcomes
Non clinical judgement - ANSWER The nurse gathers equipment for the insertion of
a Foley catheter, obtains a verbal consent from the client and follows the agency's
procedure to complete the task.
Clinical Judgement or Non clinical judgement
Clinical judgement - ANSWER Clinical judgment or non clinical judgement
The nurse discovers abnormal findings when performing a physical assessment. She
reviews the electronic health record, comparing the findings, and calls the healthcare
provider with the contrasting information. The nurse practitioner then gives new
medication orders.
, Non clinical judgement - ANSWER Clinical judgment or non clinical judgment
The student explores the client's health record, reads the history and physical
examination, and records the information on the nursing care plan
Clinical judgment - ANSWER Clinical judgment or non clinical judgment
The nurse recognizes that the client has crackles in the lower lung fields from an
accumulation of fluid. He further explores the patient's weigh, intake and output, and
medication list before documenting the findings
Non clinical judgment - ANSWER Clinical judgment or non clinical judgment
The unlicensed assistive personnel reports to the nurse that the blood pressure for a
client is very low. The nurse reports the information to the next shift
Not clinical judgment - ANSWER Clinical judgment or not clinical judgment
Without assistance, a student ambulates a client in the hallway who recently
returned from surgery
Clinical judgment - ANSWER Clinical judgement or not clinical judgment
A nurse decides to place the intravenous catheter into the client's left arm because
he is right handed
Clinical judgment - ANSWER Clinical judgment or not clinical judgment
The nurse delivers the first dose of a new blood pressure medicine that the client has
not taken previously. She assesses the blood pressure before delivery of the
medication and 1 hour afterward. Prior to the second dosage, the patient's bp is very
low and the nurse decided to hold the medication
Clinical judgment - ANSWER Clinical judgment or not clinical judgment
A client tell the nurse that the hospital food is "terrible." The nurse asks what foods
the client would prefer based on his cultural customs. She then contacts the dietary
department to determine whether adjustments can be made. After the next meal, the
nurse asks the client whether the food has improved
Need to find the truth
Openness to other options
Use of reasoned thinking
Capacity to reflect on situations - ANSWER A nurse is instructing nursing students
about incorporating clinical thinking into client care. What attributes should the nurse
include in this lesson?
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