Chapter 2. Critical Thinking & Nursing Process

MULTIPLE CHOICE

	1.	Which of the following characteristics do the various definitions of critical thinking have in common? Critical thinking:
a.	Requires reasoned thought	
b.	Asks the questions “why” or “how”	
c.	Is a hierarchical process	
d.	Demands specialized thinking skills	

ANS:	A
The definitions listed in the text as well as definitions contained in Box 2-1 state that critical thinking requires reasoning or reasoned thinking. Critical thinking is neither linear nor hierarchical. The steps involved in critical thinking are not necessarily sequential, wherein mastery of one step is necessary to proceed to the next. Critical thinking is a purposeful, dynamic, analytical process that contributes to reasoned decisions and sound contextual judgments.

(High-level question, answer not stated verbatim)
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Moderate
Page 32

PTS:	1

	2.	A few nurses on a unit have proposed to the nurse manager that the process for documenting care on the unit be changed. They have described a completely new system. Why is it important for the nurse manager to have a critical attitude? It will help the manager to:
a.	Consider all the possible advantages and disadvantages	
b.	Maintain an open mind about the proposed change	
c.	Apply the Nursing Process to the situation	
d.	Make a decision based on past experience with documentation	

ANS:	B
A critical attitude enables the person to think fairly and keep an open mind.

Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension 
Difficulty: Moderate
Page 33

PTS:	1

	3.	The nurse has just been assigned to the clinical care of a newly admitted patient. To know how best to care for the patient, the nurse uses the Nursing Process. Which step would the nurse probably undertake first?
a.	Make an assessment	
b.	Make a diagnosis	
c.	Plan outcomes	
d.	Plan interventions	

ANS:	A
Assessment is the first step of the Nursing Process. The nursing diagnosis is derived from the data gathered during assessment, outcomes from the diagnosis, and interventions from the outcomes.

Nursing Process: Assessment
Client Need: Safe and Effective Care
Cognitive Level: Application 
Difficulty: Easy
Page 38

PTS:	1

	4.	Which of the following is an example of practical knowledge? Assume all are true.
a.	The tricuspid valve is located between the right atrium and ventricle of the heart.	
b.	The pancreas does not produce enough insulin in type 1 diabetes.	
c.	When assessing the abdomen, you should auscultate before palpating.	
d.	Research shows pain medication given intravenously acts faster than medication given by other routes.	

ANS:	C
Practical knowledge is knowing what to do and how to do it, such as how to make an assessment. The others are examples of theoretical knowledge, anatomy (tricuspid valve), facts (type 1 diabetes), and research (intravenous pain medication).

(High-level question, answer not stated verbatim)
Nursing Process: Not applicable 
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
Page 41

PTS:	1

	5.	Which of the following is an example of self-knowledge? The nurse thinks, “I know that I:
a.	Should take the client’s apical pulse for 1 full minute before giving digoxin”	
b.	Should follow the client’s wishes even though it is not what I would want”	
c.	Have religious beliefs that may make it difficult to take care of some clients”	
d.	Need to honor the client’s request not to discuss his health concern with the family”	

ANS:	C
Self-knowledge is being aware of your religious and cultural beliefs and values. Taking the pulse is an example of practical knowledge. Following client wishes and honoring client requests are examples of ethical knowledge.

(High-level question, answer not stated verbatim)
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Difficult
Page 37

PTS:	1

	6.	Which of the following is the most important reason for nurses to be critical thinkers?
a.	Nurses need to follow policies and procedures.	
b.	Nurses work with other healthcare team members.	
c.	Nurses care for clients who have multiple health problems.	
d.	Nurses have to be flexible and work variable schedules.	

ANS:	C
Critical thinking is essential for client care, particularly when the care is complex, involving numerous health issues. Following policies and procedures does not necessarily require critical thinking; working with others or being flexible and working different schedules do not necessarily require critical thinking.

(High level question, answer not stated verbatim) 
Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
Page 33

PTS:	1

	7.	The nurse administering pain medication every 4 hours is an example of which aspect of patient care?
a.	Assessment data	
b.	Nursing diagnosis	
c.	Patient outcome	
d.	Nursing intervention	

ANS:	D
Interventions are activities that will help the patient achieve a goal, such as administering pain-relieving medication. An example of assessment data might be: “Patient reports pain is a 5 on a 1 to 10 scale.” The nursing diagnosis would be “pain.” The nurse might define the patient outcome in this scenario as, “The patient will state the level of pain is less than 4.” 

(High-level question, answer not stated verbatim)
Nursing Process: Interventions
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
Page 38

PTS:	1

	8.	How does a nursing diagnosis differ from a medical diagnosis? A nursing diagnosis is:
a.	Terminology for the client’s disease or injury	
b.	A part of the client’s medical diagnosis	
c.	The client’s presenting signs and symptoms	
d.	A client’s response to a health problem	

ANS:	D
A nursing diagnosis is the client’s response to actual or potential health problems.

Nursing Process: Diagnosis
Client Need: Safe and Effective Care
Cognitive Level: Knowledge
Difficulty: Easy
Page 38

PTS:	1

	9.	What do critical thinking and the Nursing Process have in common?
a.	They are both linear processes used to guide one’s thinking.	
b.	They are both thinking methods used to solve a problem.	
c.	They both use specific steps to solve a problem.	
d.	They both use similar steps to solve a problem.	

ANS:	B
Critical thinking and the Nursing Process are ways of thinking that can be used in problem-solving (although critical thinking can be used for other than problem-solving applications). Neither method of thinking is linear. The Nursing Process has specific steps; critical thinking does not.

Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Difficult
Page 39

PTS:	1

	10.	A nurse admits a patient to the unit after completing a comprehensive interview and physical examination. To develop a nursing diagnosis, the nurse must now:
a.	Analyze the assessment data	
b.	Consult standards of care	
c.	Decide which interventions are appropriate	
d.	Ask for the client’s perceptions of her health problem	

ANS:	A
The basis of the nursing diagnosis is the assessment data. Standards of care are referred to when establishing nursing interventions. Customizing interventions personalizes nursing care. Asking the patient about her perceptions is a method to validate whether the nurse has chosen the correct nursing diagnosis and would probably have been done during the comprehensive assessment.

Nursing Process: Diagnosis
Client Need: Safe and Effective Care
Cognitive Level: Application 
Difficulty: Moderate
Page 38

PTS:	1

	11.	The nurse developed a care plan for a patient to help prevent Impaired Skin Integrity. She has made sure that nursing assistive personnel change the patient’s position every 2 hours. In the evaluation phase of the Nursing Process, which of the following would the nurse do first?
a.	Determine whether she has gathered enough assessment data	
b.	Judge whether the interventions achieved the stated outcomes	
c.	Follow up to verify that care for the nursing diagnosis was given	
d.	Decide whether the nursing diagnosis was accurate for the patient’s condition	

ANS:	B
The evaluation phase judges whether the interventions were effective in achieving the desired outcomes and helped to alleviate the nursing diagnosis. This must be done before examining the Nursing Process steps and revising the care plan.

Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Moderate
Page 38

PTS:	1

	12.	In caring for a patient with both diabetes and Impaired Skin Integrity (comorbidity), the nurse draws on her knowledge of diabetes and skin integrity. In a spirit of inquiry, she looks up the latest guidelines for providing skin care and includes them in the plan of care. The nurse provides skin care according to the procedural guidelines and begins regular monitoring to evaluate the effectiveness of the interventions. The nurse has demonstrated:
a.	Full-spectrum nursing	
b.	Critical thinking	
c.	Nursing Process	
d.	Nursing knowledge	

ANS:	A
Full-spectrum nursing involves the use of critical thinking, nursing knowledge, Nursing Process, and patient situation. Although the other answers are important for planning and delivering nursing care, they do not reflect all the nurse has demonstrated.

(High level question, answers not stated verbatim)
Nursing Process: Not applicable
Client Need: PHSI
Cognitive Level: Analysis
Difficulty: Difficult
Pages 39-42

PTS:	1

	13.	It is important for nurses to be critical thinkers because:
a.	All clients are unique and have individual needs and differences	
b.	All nursing actions are based on theoretical knowledge	
c.	Nurses choose their actions primarily by following professional guidelines	
d.	Nurses provide care based on individual client preferences	

ANS:	A
All clients are unique and have individual differences. Nursing actions are not solely based on theoretical knowledge. Actions are based on theoretical knowledge, practical knowledge, and self-knowledge. Following guidelines does not usually require critical thinking, and guidelines often do not offer adequate help in managing complex situations. Client preferences are certainly included in the plan of care but they do not cover the broad spectrum of being a critical thinker—it does not require critical thinking merely to do what the client prefers.

Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Moderate
Page 33

PTS:	1

	14.	A full-spectrum nurse uses a critical-thinking model to organize her thinking when caring for a patient. The nurse realizes she lacks some facts about the patient’s pathophysiology, so she makes sure to use a credible source for the information. She considers the alternatives for action, then again looks up some information. Before deciding what to do, she thinks about the patient’s family situation. What aspect of a critical-thinking model does this best illustrate? The nurse is:
a.	Following model guidelines for specific interventions	
b.	Using linear processes to think critically	
c.	Moving back and forth between steps, and not thinking sequentially	
d.	Using self-knowledge in the decision-making process	

ANS:	C
Critical thinking is not sequential, and critical-thinking models are not applied sequentially. Critical-thinking models do not proceed from top to bottom, nor are they linear. Nurses may jump back and forth between the various steps. Critical-thinking models do not prescribe guidelines for specific interventions. Although self-knowledge may be used as part of a decision-making process, this is not the best answer to complete the statement. The only way self-knowledge is involved in this scenario is that the nurse recognizes that she is lacking some information/knowledge.

Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Difficult
Pages 39-42

PTS:	1

	15.	Which is the best example of a critical-thinking attitude? The nurse:
a.	Has extensive knowledge of principles and theories	
b.	Has a lively curiosity and enjoys discovering new ways of doing things	
c.	Applies the problem-solving process he was taught in nursing school	
d.	Responds to patients mainly on the basis of what is socially approved	

ANS:	B
Attitudes are more akin to feelings and traits than to intellectual skills. Therefore, extensive knowledge is not a good example of an attitude. Attitudes are addressed in nursing school but it is unlikely that one can “teach” attitudes. A problem-solving process does necessarily require critical thinking; moreover, applying a process simply because one learns it in school would mean the person is not demonstrating an attitude of intellectual independence. Society and culture do help to form attitudes, but that is not the same as basing actions on what is socially approved. Again, that would not demonstrate independent thinking or any of the other critical-thinking attitudes.

Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Difficult
Page 32

PTS:	1

	16.	What is the best description of the Nursing Process? The Nursing Process is:
a.	A way to create nursing knowledge for use in practice	
b.	A systematic view of a specific phenomenon in nursing	
c.	A linear process for providing nursing care	
d.	A systematic process for the delivery of nursing care	

ANS:	D
The Nursing Process is central to nursing care. It is a systematic problem-solving process that guides all nursing actions. The process does not create knowledge. Knowledge is created through theoretical and practical research. The Nursing Process is not a view of a specific phenomenon. Finally, the Nursing Process is not linear; the steps are reflexive and overlapping.

Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Easy
Page 37

PTS:	1

	17.	The nurse is caring for a client with heart failure. She begins to obtain the client’s history and vital signs and then listens to breath sounds. The nurse is practicing which aspect of the Nursing Process?
a.	Assessment	
b.	Planning interventions	
c.	Planning outcomes	
d.	Evaluation	

ANS:	A
Obtaining the history, auscultating breath sounds, and obtaining vital signs are part of the assessment process. In the assessment step, the nurse gathers patient data and information. In the planning interventions step, the nurse chooses nursing activities aimed at meeting patient goals (and thus relieving the patient’s problem). In the planning outcomes phase, the nurse and patient identify goals for the patient’s health—expected or desired outcomes of the care. After performing nursing activities, in the evaluation stage the nurse reassesses the patient to determine whether goals have been met.

Nursing Process: Assessment
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
Page 38

PTS:	1

	18.	The nurse is caring for a client with skin breakdown of the coccyx area. The physician has ordered a medication to be applied to the area. In applying the medication, the nurse is practicing which aspect of the Nursing Process?
a.	Assessment	
b.	Planning interventions	
c.	Implementation	
d.	Evaluation	

ANS:	C
Application of a medication to the coccyx area is an “action.” The nurse both plans and carries out the intervention. The nurse carries out (and records) interventions in the implementation phase. Evaluation is done after the plan (or nursing action) is implemented.

Nursing Process: Implementation
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
Page 38

PTS:	1

	19.	The nurse documents in the client plan of care that the wound treatment to the client’s left foot has resulted in wound healing. She removed the Skin Integrity diagnosis from the plan of care. The nurse is using which aspect of the Nursing Process?
a.	Assessment	
b.	Evaluation	
c.	Planning outcomes	
d.	Planning interventions	

ANS:	B
Documenting nursing interventions and a patient’s immediate responses (e.g., expressed pain, became restless) is done in the implementation stage. However, in this scenario the nurse also documented that the wound was healing and she removed the nursing diagnosis from the care plan. This demonstrates evaluation.

Nursing Process: Evaluation
Client Need: Safe and Effective Care
Cognitive Level: Analysis
Difficulty: Difficult
Page 38

PTS:	1

	20.	The nurse enters a room to find the client sitting up in the chair, crying. The nurse best displays a critical-thinking attitude, as well as a caring attitude, by:
a.	Telling the client that she’ll be back to chat after she sees her other clients	
b.	Calling the family to come and sit with the client	
c.	Trying to determine the reasons for the client’s crying	
d.	Placing a “do not disturb” sign on the door to protect the client’s privacy	

ANS:	C
The nurse should try to find out why the client is crying so that she may intervene appropriately and correctly. Postponing talking with the client does not assist the client nor does it enable the nurse to make an appropriate intervention. Telling the client she’ll be back may cause the client to feel that her needs are less important. Calling the family may be helpful to the client once the nurse identifies why the client is crying. However, depending on the reason, the family may not be at all helpful. A “do not disturb” sign, without obtaining more information, may isolate the client. Upon further exploration, the nurse may discover that the client is already feeling alone and that she does not want or need privacy right now. 

Nursing Process: Implementation
Client Need: PSI
Cognitive Level: Application
Difficulty: Moderate
Pages 37-39

PTS:	1

	21.	Select the answer that best completes the following statement: The primary purpose of employing the full-spectrum nursing model is to:
a.	Assist nurses in testing psychomotor skills	
b.	Have a positive effect on a client’s health outcomes	
c.	Adequately use all aspects of the Nursing Process	
d.	Assist nurses in completing their work on time	

ANS:	B
The question is asking for the best answer to complete the statement. The best answer is “to have a positive effect on a client’s health outcomes,” which is also a goal of nursing in general. The full-spectrum model may assist nurses in performing psychomotor skills and even in completing their work on time—especially when something unexpected occurs. However, that is not the focus of the model. Full-spectrum nursing would likely improve the nurse’s problem-solving ability (as in the Nursing Process); however, that is not the end purpose of full-spectrum nursing. It is merely a means to achieving the purpose of positively affecting health outcomes.

Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Comprehension
Difficulty: Moderate
Pages 39-41

PTS:	1

	22.	The nurse has gathered her assessment data and notes several significant changes in the client’s health status. The client’s weight has increased by 5 lb over the past 24 hours, he is short of breath, and crackles are auscultated at both lung bases. To which step of the Nursing Process should the nurse proceed after organizing these data?
a.	Diagnosis	
b.	Planning	
c.	Implementation	
d.	Evaluation	

ANS:	A
After gathering and analyzing the assessment data, the nurse should next formulate a nursing diagnosis. The other options are not done until after the problem has been diagnosed. The problem is used to plan goals, which are then used to plan interventions. After implementing the intervention(s), evaluation is done to identify change in health status and determine whether goals have been met. 

Nursing Process: Diagnosis
Client Need: Safe and Effective Care
Cognitive Level: Application
Difficulty: Moderate
Page 38

PTS:	1

MULTIPLE RESPONSE

	1.	Which aspects of healthcare are affected by a client’s culture? Select all that apply.
a.	How the client views healthcare	
b.	How the client views illness	
c.	Whether insurance will pay for healthcare services	
d.	The types of treatments the client will accept	
e.	When the client will seek healthcare services	
f.	The environment in which the healthcare services are provided	
g.	The ease of accessibility of healthcare services	

ANS:	A, B, D, E
Culture impacts clients’ views of health and healthcare. It influences how they will define illness, when they will seek healthcare, and what treatments are acceptable in their culture. How services are paid for is related to social environment and economic status. Regardless of culture, anyone can be affected by previous healthcare experiences, the environment in which healthcare is provided, and accessibility of services.

Nursing Process: Not applicable
Client Need: Safe and Effective Care
Cognitive Level: Knowledge
Difficulty: Moderate
Page 33

PTS:	1

	2.	Caring is a central concept in nursing that involves which of the following? Select all that apply.
a.	Treating all clients with a similar disease in exactly the same way	
b.	Responding compassionately to client needs	
c.	Acting in ways to preserve human dignity	
d.	Connecting with others to give and receive help	
e.	Using active listening	

ANS:	B, C, D, E
Treating all clients in exactly the same way just because they share similar disease processes does not consider their uniqueness nor honor their personhood—and thus does not reflect caring. The other options are all aspects of caring.

Nursing Process: Not applicable
Client Need: PSI
Cognitive Level: Analysis
Difficulty: Moderate
Page 39

PTS:	1