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Integrated Processes 7 Test 5 u Integrated Processes 481 UNIT III Integrated Processes and the NCLEX-RNW Test Plan 476 475
u CHAPTER 7 Integrated Processes and the NCLEX-RN‚ Test Plan INTEGRATED PROCESSES In the new test plan implemented in April 2010, the National t Box 7-2 Caring A client who has end-stage cancer is admitted to a hospice care Council of State Boards of Nursing (NCSBN) identified a test facility from her home. Which intervention should the nurse imple- plan framework based on Client Needs. This framework was ment to address the client’s psychosocial needs? selected on the basis of the analysis of the findings in a practice 1. Administer total care for the client. 2. Engage the client in social activities. analysis study of newly licensed registered nurses in the United 3. Allow the client to verbalize feelings. States. This study identified the nursing activities performed 4. Provide pain medication every 4 hours. by entry-level nurses across all settings for all clients. The NCSBN identified four major categories of Client Needs. These Answer: 3 categories—Safe and Effective Care Environment, Health Rationale: Promotion and Maintenance, Psychosocial Integrity, and The client is experiencing loss from two life-changing experiences: Physiological Integrity—are described in Chapter 6. her poor prognosis and the loss of control over the environment, The 2010 NCLEX-RN test plan also identifies four processes independence, and privacy that accompanies admission to a hos- that are fundamental to the practice of nursing. These processes pice care facility. To meet the client’s psychosocial needs, the are integrated throughout the four major categories of Client nurse should promote a therapeutic relationship and allow the cli- ent to verbalize her feelings. Options 1 and 4 manage physical Needs. The test plan for NCLEX-RN identifies these compo- needs. Although total care may be necessary, it does not address nents as Integrated Processes, and they are as follows: Caring, psychosocial needs. Providing pain medication is indicated as part Communication and Documentation, Teaching and Learning, of effective pain management; however, this can interfere with ther- and Nursing Process (Box 7-1). apeutic communication if the client is too sedated. Engaging the client in social activities is unlikely to effectively meet the client’s psychosocial needs relating to loss; it is more likely to help dimin- CARING ish loneliness and isolation. Caring is the essence of nursing, and it is basic to any helping References relationship. Caring is central to every encounter that a nurse Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical management may have with a client. Through caring, the nurse humanizes for positive outcomes (8th ed.). St. Louis: Saunders. the client. Treating the client with respect and dignity is a true Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2011). expression of caring. In the technological environment of Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis: Mosby. health care, emphasizing the client’s individuality counter- Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.). St. Louis: acts any potential process of depersonalization. Caring is Mosby. an Integrated Process of the test plan for NCLEX-RN and the NCSBN describes caring in part as a role of the nurse in providing encouragement, hope, support, and compassion. support. Remember that this examination is all about nursing, The process of caring is nuclear to all Client Needs compo- and nursing is caring (Box 7-2)! nents of the test plan. For the NCLEX-RN, the process of caring is primary. It is very easy to become involved with looking at a question from COMMUNICATION AND DOCUMENTATION a technological viewpoint. However, the process of caring must The process of communication occurs as a nurse interacts be addressed when reading a test question and when selecting either verbally or nonverbally with a client. Therapeutic com- an option. Always address the client’s feelings and provide munication techniques are essential to an effective nurse–client t relationship. Communication-type test questions are inte- Box 7-1 Integrated Processes grated throughout the NCLEX-RN test plan, and they may address a client situation in any health care setting. The NCSBN Caring describes communication as the verbal and nonverbal inter- Communication and Documentation actions that occur in the health care environment. Teaching and Learning When answering a question on the NCLEX-RN, the use of Nursing Process therapeutic communication techniques indicates a correct476
CHAPTER 7 Integrated Processes and the NCLEX-RN‚ Test Plan s 477tBox 7-3 Communication and Documentation Communication Documentation A client with myasthenia gravis is having difficulty with the motor as- The nurse finds a client lying on the floor. The nurse performs an as- pects of speech. The client has difficulty forming words, and the voice sessment, assists the client back to bed, and completes an incident has a nasal tone. The nurse should plan to use which communication report. Which should the nurse document on the incident report? strategy when working with this client? 1. The client fell onto the floor. 1. Encourage the client to speak quickly. 2. The client climbed over the side rails. 2. Nod continuously while the client is speaking. 3. The client was found lying on the floor. 3. Repeat what the client has said to verify the message. 4. The nurse was the only responder to the event. 4. Engage the client in lengthy discussions to strengthen the Answer: 3 voice. Rationale: Answer: 3 The incident report should contain the client’s name, age, and Rationale: diagnosis as well as a factual description of the incident, any injuries The client has speech that is nasal in tone because of cranial nerve experienced by those involved, and the outcome of the situation. involvement in the muscles that govern speech. The nurse should lis- Option 3 is the only choice that describes the facts as observed by ten attentively and verbally verify what the client has said. Other help- the nurse. The nurse did not witness the events that led up to finding ful techniques involve asking questions that require a “yes” or “no” the client on the floor; thus he or she cannot comment on how the response and developing alternative communication methods (e.g., client got to the floor (options 1 and 2). Option 4 is unsuitable docu- letter board, picture board, pen and paper, flash cards). Encouraging mentation on an incident report, because it implies that other staff the client to speak quickly is inappropriate and counterproductive. members failed to respond to the event. Continuous nodding may be distracting and is unnecessary. Lengthy References discussions will tire the client rather than strengthen the voice. Huber, D. (2010). Leadership and nursing care management (4th ed.). St. Louis: Saunders. Reference Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.). St. Louis: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient- Mosby. centered collaborative care (6th ed.). St. Louis: Saunders.option, and the use of nontherapeutic communication tech-niques indicates an incorrect option. In additional, somecommunication-type questions may focus on psychosocial t Box 7-4 Teaching and Learning A nurse is preparing a plan regarding home care instructions for theissues or issues related to client anxiety, fears, or concerns. parents of a child with generalized tonic-clonic seizures who isFor communication-type questions, always focus on the being treated with oral phenytoin (Dilantin). The nurse includesclient’s feelings first. If an option reflects the client’s feelings, instructions in the plan regarding:anxiety, or concerns, select that choice. 1. Monitoring the child’s intake and output daily Documentation is a critical component of a nurse’s respon- 2. Providing oral hygiene, especially care of the gumssibilities. The process of documentation serves many purposes; 3. Administering the medication 1 hour before food intake 4. Checking the child’s blood pressure before the administra-it provides a comprehensive representation of the client’s tion of the medicationhealth status and the care given by all members of the healthcare team. There are many methods of documentation, but Answer: 2the responsibilities surrounding this practice remain the same. Rationale:The NCSBN describes documentation as the activities associ- Phenytoin is an anticonvulsant medication and causes gum bleed-ated with the client’s medical record that reflect standards of ing and hyperplasia; therefore a soft toothbrush and gum massagepractice and accountability. should be instituted to diminish this complication and prevent When answering a question on the NCLEX-RN related to trauma. Intake, output, and blood pressure are not affected by thisdocumentation, consider the ethical and legal responsibilities medication. Directions for administration of this medication in-related to documentation and the specific guidelines related clude administering it with food to minimize gastrointestinal upset.to both narrative and computerized documentation systems Reference(Box 7-3). McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed.). St. Louis: Elsevier.TEACHING AND LEARNINGClient and family education is a primary nursing responsibil- to teaching and learning theory. If a test question addresses cli-ity. The NCSBN describes this process as facilitating the acqui- ent education, remember that client motivation and readinesssition of knowledge, skills, and attitudes that lead to a change to learn is the first priority (Box 7-4).in behavior. The principles related to the teaching and learning process areused when the nurse functions as a teacher. The nurse must re- NURSING PROCESSmember that the assessment of the client’s readiness and motiva- The steps of the nursing process provide a systematic and orga-tion to learn is the initial step in the teaching and learning process. nized method of problem solving and providing care to clients. When answering a question on the NCLEX-RN related to As noted by the NCSBN, the steps include assessment, analysis,the teaching and learning process, use the principles related planning, implementation, and evaluation (Box 7-5).
s478 UNIT III Integrated Processes t Box 7-5 Assessment Steps of the Nursing Process t Box 7-6 Nursing Process: Assessment A clinic nurse in a well-baby clinic is collecting data regarding the Analysis motor development of a 15-month-old child. Which of the following Planning is the highest level of development that the nurse would expect to Implementation observe in this child? Evaluation 1. The child turns a doorknob. 2. The child unzips a large zipper. 3. The child builds a tower of two blocks. 4. The child puts on simple clothes independently. Assessment Answer: 3 Assessment is the first step of the nursing process. It involves a Rationale: systematic method of collecting data about a client to identify At the age of 15 months, the nurse would expect that the child actual and potential client health problems and establish a da- could build a tower of two blocks. A 24-month-old child would be tabase. The database provides the foundation for the remain- able to turn a doorknob and unzip a large zipper. At the age of ing steps of the nursing process; therefore, a thorough and 30 months, the child would be able to put on simple clothes adequate database is essential. Data collection begins with independently. the first contact with the client. During all successive contacts, Reference the nurse continues to collect information that is significant McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child and relevant to the needs of that client. nursing (3rd ed.). St. Louis: Elsevier. During the assessment process, the nurse collects data about the client from a variety of sources. The client is the pri- mary source of data. Family members and significant others are secondary sources of assessment data, and these sources may cultural background. The nurse then draws conclusions regard- supplement or verify the information provided by the client. ing the client’s unique needs and health care risks or problems. Data may also be obtained from the client’s record through Client health problems are categorized as at-risk problems the medical history, laboratory results, and diagnostic reports. that require prevention or as actual problems that are being Medical records from previous admissions may provide addi- managed or require interventions. The nurse reports the results tional information about the client. The nurse may also obtain of the analysis to the appropriate members of the health care information through consultation with other health care team team and documents the client’s unique health care problems, members who have had contact with the client. needs, or both. A thorough database is obtained with the use of a health On the NCLEX-RN, questions that address the process of history and a physical assessment. The information collected analysis are difficult, because they require an understanding by the nurse includes both subjective and objective data. of the principles of physiological responses as well as an inter- Subjective data include the information that the client states. pretation of the data on the basis of assessment findings. Anal- Objective data are the observable, measurable pieces of infor- ysis questions require critical thinking and determining the mation about the client, including measurements such as vital rationale for therapeutic interventions that may be addressed signs and laboratory findings, as well as information obtained in the case event. These questions may address the formulation by observing the client. Objective data also include clinical of a nursing diagnosis and the communication and documen- manifestations, such as the signs and symptoms of an illness tation of the results of the process of analysis (Box 7-7). or disease. The process of assessment additionally consists of confirm- t ing and verifying client data, communicating information obtained through the assessment process, and documenting Box 7-7 Nursing Process: Analysis assessment findings in a thorough and accurate manner. A client is admitted to the cardiac unit and placed on telemetry. On the NCLEX-RN, remember that assessment is the first A nurse reviews the client’s laboratory values and notes that the step of the nursing process. When answering these types of potassium level is 6.3 mEq/L. When analyzing the cardiac rhythm, questions, focus on the data in the question, and select the the nurse would expect to note which electrocardiogram (ECG) finding? option that addresses an assessment action. In addition, use 1. A sinus tachycardia with an extra U wave the skills of prioritizing and the ABCs—airway, breathing, 2. A sinus rhythm with a tall, peaked T wave and circulation—to answer the question (Box 7-6). 3. A sinus rhythm with a depressed ST segment 4. A sinus tachycardia with a prolonged QT interval Analysis Answer: 2 Analysis is the second step of the nursing process. During this Rationale: A potassium level of more than 5.1 mEq/L indicates hyperkalemia, step, the nurse focuses on the data gathered during the assess- which can be detected on ECG by the presence of a tall, peaked ment process and identifies actual or potential health care T wave. A U wave and a depressed ST segment are present with needs, problems, or both. During this process, the nurse sum- hypokalemia. A prolonged QT interval indicates hypocalcemia. marizes and interprets the assessment data, organizes and val- idates the data, and determines the need for additional data. Reference Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient- Client assessment data are compared with the normal expected centered collaborative care (6th ed.). Philadelphia: Saunders. findings and behaviors for the client’s age, education, and
Planning CHAPTER 7 Integrated Processes and the NCLEX-RN‚ Test Plan managing client care, providing care to achieve established s 479 goals, supervising and coordinating the delivery of client care,Planning is the third step of the nursing process. This step in- and communicating and documenting the nursing interven-volves the functions of setting priorities, determining goals of tions and client responses.care, planning actions, collaborating with other health care During implementation, the nurse uses intellectual, inter-team members, establishing evaluative criteria, and communi- personal, and technical skills. Intellectual skills involve criticalcating the plan of care. thinking, problem solving, and making judgments. Interper- Setting priorities assists the nurse with organizing and plan- sonal skills involve the ability to communicate, listen, and con-ning care that solves the most urgent problems. Priorities may vey compassion. Technical skills relate to the performance ofchange as the client’s level of wellness changes. Both actual and treatments and procedures and the use of necessary equipmentat-risk problems should be considered when establishing pri- when providing care to the client.orities. Actual problems are usually more important than at- The nurse independently implements actions that includerisk problems. However, at-risk problems may at times take activities that do not require a physician’s prescription. Theprecedence over actual problems. nurse also implements actions collaboratively on the basis of After priorities are established, the client and the nurse mu- the physician’s prescriptions. Sound nursing judgment andtually decide on the expected goals. The selected goals serve as a working with other health care members is incorporated intoguide for selecting nursing interventions and determining the the process of implementation. The implementation step con-criteria for evaluation. Before nursing actions are implemen- cludes when the nurse’s actions are completed and when theseted, mechanisms to determine goal achievement and the effec- actions, including their effects and the client’s response, aretiveness of nursing interventions are established. Unless communicated and documented.criteria have been predetermined, it is difficult to know The NCLEX-RN is an examination about nursing, so focuswhether the goal has been achieved or the problem has been on the nursing action rather than the medical action, unless theresolved. question is asking what prescribed medical action is antici- It is important for the nurse to both identify health or social pated (Box 7-9).resources available to the client and collaborate with otherhealth care team members when planning the delivery of care. EvaluationThe nurse must communicate the plan of care, review the planof care with the client, and document the plan of care thor- Evaluation is the fifth and final step of the nursing process. Theoughly and accurately. process of evaluation identifies the degree to which the nursing When answering questions on the NCLEX-RN, remember diagnoses, plans for care, and interventions have beenthat this is a nursing examination. In addition, remember that successful.actual problems are usually more important than at-risk prob- Although evaluation is the final step of the nursing process,lems, and physiological needs are usually the priority (Box 7-8). it is an ongoing and integral component of each step. The pro- cess of data collection and assessment is reviewed to determine if sufficient information was obtained and the informationImplementation obtained was specific and appropriate. The nursing diagnosesImplementation is the fourth step of the nursing process. It in- are evaluated for accuracy and completeness on the basis of thecludes initiating and completing nursing actions that are re- client’s specific needs. The plan and expected outcomes are ex-quired to accomplish defined goals. This step is the action amined to determine whether they are realistic, achievable,phase that involves counseling, teaching, organizing and t Box 7-9 Nursing Process: ImplementationtBox 7-8 Nursing Process: Planning A nurse is planning care for a child with an infectious and commu- A nurse in the postpartum unit checks the temperature of a client who delivered a healthy newborn infant 4 hours ago. The mother’s temperature is 100.8 F. The nurse provides oral hydration to the nicable disease. The nurse determines that the primary goal is mother and encourages fluids. Four hours later, the nurse rechecks that: the temperature and notes that it is still 100.8 F. Which nursing 1. The child will experience mild discomfort. action is appropriate? 2. The public health department will be notified. 1. Notify the physician. 3. The child will not spread the infection to others. 2. Document the temperature. 4. The child will experience only minor complications. 3. Increase the intravenous fluids. 4. Continue hydration and recheck the temperature 4 hours Answer: 3 later. Rationale: Answer: 1 The primary goal for a child with an infectious and communicable disease is to prevent the spread of the infection to others. It is also Rationale: important for the nurse to prevent discomfort as much as possible. In the postpartum client, a temperature of more than 100.4 F at Although the health department may need to be notified at some two consecutive readings is considered febrile, and the physician point, it is not the primary goal. The child should experience no should be notified. Options 2, 3, and 4 are inappropriate actions complications. at this time. Reference Reference Hockenberry, M., Wilson, D. (2009). Wong’s essentials of pediatric nursing McKinney, E., James, S., Murray, S., Ashwill, J. (2009). Maternal-child (8th ed.). St. Louis: Mosby. nursing (3rd ed.). St. Louis: Elsevier.
s480 UNIT III Integrated Processes t Box 7-10 Nursing Process: Evaluation A client has been given a prescription for a course of azithromycin process are the communication of evaluation findings and the process of documenting the client’s response to treatment, care, and teaching. (Zithromax). The nurse determines that the medication is having Evaluation-type questions on the NCLEX-RN may be writ- the intended effect if which of the following is noted? ten to address a client’s response to treatment measures or de- 1. The pain is relieved. termine a client’s understanding of the prescribed treatment 2. The blood pressure is lowered. measures (Box 7-10). 3. The joint discomfort is reduced. 4. The signs and symptoms of infection are relieved. REFERENCES Black, J., Hawks, J. (2009). Medical-surgical nursing: Clinical manage- Answer: 4 ment for positive outcomes (8th ed.). St. Louis: Saunders. Rationale: Hockenberry, M., Wilson, D. (2009). Wong’s essentials of pediatric Azithromycin is a macrolide antibiotic that is used to treat infection. nursing (8th ed.). St. Louis: Mosby. It is not prescribed for the treatment of pain, blood pressure, or Hodgson, B., Kizior, R. (2012). Saunders nursing drug handbook 2012. joint discomfort. St. Louis: Saunders. Huber, D. (2010). Leadership and nursing care management (4th ed.). Reference St. Louis: Saunders. Hodgson, B., Kizior, R. (2012). Saunders nursing drug handbook 2012. Ignatavicius, D., Workman, M. (2010). Medical-surgical nursing: St. Louis: Saunders. Patient-centered collaborative care (6th ed.). St. Louis: Saunders. Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., Camera, I. (2011). Medical-surgical nursing: Assessment and management of clinical prob- lems (8th ed.). St. Louis: Mosby. measurable, and effective. Interventions are examined to deter- McKinney, E., James, S., Murray, S., Ashwill, J. (2009). Maternal-child nursing (3rd ed.). St. Louis: Elsevier. mine their effectiveness for achieving the expected outcomes. National Council of State Boards of Nursing. (2010). 2010 Because evaluation is an ongoing process, it is vital to all NCLEX-RNW detailed test plan. Chicago: Author. steps of the nursing process. It is the continuous process of National Council of State Boards of Nursing. NCSBN Web Site: comparing actual outcomes with the expected outcomes of www.ncsbn.org Accessed 12.02.10. care, and it provides the means for determining the need to Potter, P., Perry, A. (2009). Fundamentals of nursing (7th ed.). modify the plan of care. Inherent in this step of the nursing St. Louis: Mosby.