CLINICAL REASONING MIDTERM EXAM 2024/2025 LATEST
WITH ACCURATE ANSWERS.
Put the steps of the nursing process in order
assess
concept
plan
implement
eval
a key point about the nursing process is
it applies to all patients and helps achieve quality care
what is the primary purpose of the nursing process?
to provide a framework for sound nursing practice
(blank) are the signs and symptoms, or cues, that validate or confirm concepts that are
used in the diagnosis step of the nursing process?
defining characteristics
what is etiology?
how something originates
what is an effective strategy to improve focus and problem solving?
if then thinking
when is a focused assessment best used?
when the patient presents with a specific complaint
what is included in an admission assessment?
comprehensive, holistic data
previous surgeries
start with problem that brought them in
rule out and identify problems
-admission, current meds, past hospitalizations, surgeries, nutritional status, complete
physical assessment
what is included in a focused assessment?
identify specific problem and assess that area + vitals
, what is included in an emergent assessment?
when client is in life threatening condition
ABC, CPR
________________ SSA height 5 ft 10 in and weight 104 pounds, homeless shelter
staff reports seeing patient begging for food several times/week, serum total protein
level 4.5 g/dL; Albumin 2.8 g/dL
Nutrition
Priority concept is Oxygenation R/T anxiety
SSAs: RR 22-28, patient's report of feeling "panicked and unable to breathe", nasal
flaring, patient reports feeling lightheaded
Overall Outcome: Patient will report effective oxygenation by the shift.
Outcome Criteria: Patient's RR will be between 16-20 breaths/minute throughout shift.
Choose the most appropriate set of worded interventions.
1. Encourage deep breathing, coughing and incentive spirometer five times every hour.
2. Monitor RR and oxygen saturation once each shift.
3. Instruct patient to report changes in breathing immediately.
4. Instruct the patient to breathe slowly, counting to 3 during the inhale and during the
exhale
.5. Suggest 2 possible coping strategies this morning to be used the next time they feel
anxious.
345
You are caring for a 48 year old female admitted to the unit after having an orthopedic
surgery. Based on her SSAs, you select the concept of Safety: Tissue/Skin Integrity as
her priority concept.
Which of the following is an appropriate overall outcome for this concept?
will have improved skin integrity by discharge
You are caring for a 48 year old female admitted to the unit after having an orthopedic
surgery. Based on her SSAs, you select the concept of Safety: Tissue/Skin Integrity as
her priority concept.
Which of the following is an appropriate nursing intervention for this concept?
Will educate patient regarding nutritonal intake needed for wound healing by end of
shift.
Nursing Diagnosis 1: _________________________________ R/T decreased access
to adequate food AEB height 5 ft 9 in and weight 129 pounds, homeless shelter staff
reports seeing patient begging for food several x/wk., Low serum protein level
nutrition imbalance (most focused)
WITH ACCURATE ANSWERS.
Put the steps of the nursing process in order
assess
concept
plan
implement
eval
a key point about the nursing process is
it applies to all patients and helps achieve quality care
what is the primary purpose of the nursing process?
to provide a framework for sound nursing practice
(blank) are the signs and symptoms, or cues, that validate or confirm concepts that are
used in the diagnosis step of the nursing process?
defining characteristics
what is etiology?
how something originates
what is an effective strategy to improve focus and problem solving?
if then thinking
when is a focused assessment best used?
when the patient presents with a specific complaint
what is included in an admission assessment?
comprehensive, holistic data
previous surgeries
start with problem that brought them in
rule out and identify problems
-admission, current meds, past hospitalizations, surgeries, nutritional status, complete
physical assessment
what is included in a focused assessment?
identify specific problem and assess that area + vitals
, what is included in an emergent assessment?
when client is in life threatening condition
ABC, CPR
________________ SSA height 5 ft 10 in and weight 104 pounds, homeless shelter
staff reports seeing patient begging for food several times/week, serum total protein
level 4.5 g/dL; Albumin 2.8 g/dL
Nutrition
Priority concept is Oxygenation R/T anxiety
SSAs: RR 22-28, patient's report of feeling "panicked and unable to breathe", nasal
flaring, patient reports feeling lightheaded
Overall Outcome: Patient will report effective oxygenation by the shift.
Outcome Criteria: Patient's RR will be between 16-20 breaths/minute throughout shift.
Choose the most appropriate set of worded interventions.
1. Encourage deep breathing, coughing and incentive spirometer five times every hour.
2. Monitor RR and oxygen saturation once each shift.
3. Instruct patient to report changes in breathing immediately.
4. Instruct the patient to breathe slowly, counting to 3 during the inhale and during the
exhale
.5. Suggest 2 possible coping strategies this morning to be used the next time they feel
anxious.
345
You are caring for a 48 year old female admitted to the unit after having an orthopedic
surgery. Based on her SSAs, you select the concept of Safety: Tissue/Skin Integrity as
her priority concept.
Which of the following is an appropriate overall outcome for this concept?
will have improved skin integrity by discharge
You are caring for a 48 year old female admitted to the unit after having an orthopedic
surgery. Based on her SSAs, you select the concept of Safety: Tissue/Skin Integrity as
her priority concept.
Which of the following is an appropriate nursing intervention for this concept?
Will educate patient regarding nutritonal intake needed for wound healing by end of
shift.
Nursing Diagnosis 1: _________________________________ R/T decreased access
to adequate food AEB height 5 ft 9 in and weight 129 pounds, homeless shelter staff
reports seeing patient begging for food several x/wk., Low serum protein level
nutrition imbalance (most focused)
