Fundamentals of Nursing and Midwifery 2e

Unit III Thoughtful practice and the process of care

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as a basis for nursing and midwifery care. The fact that this is also hospital policy ( b ) is a secondary reason. 3. The correct answer is d . Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone ( b ) or corrected ( a ). This is not a life-threatening event, and thus there is no need for an emergency assessment ( c ). 4. The correct answer is b . Once you learn what consti- tutes the minimum amount of data required, you can adapt this to any nursing situation. It is not true that each assessment is the same even when you are using the same minimum data set ( a ), or that each assessment is uniquely different ( c ). Answer d is incorrect because relying solely on standard agency assessment tools does not allow for individualised person-centred care or critical thinking. 5. The correct answer is a . A personal report of ‘feeling nauseated’ cannot be perceived or validated by the nurse/ midwife, and this is subjective data, not objective ( b ) or overt ( d ), which are observable and measurable. Answer c is wrong since signs are examples of objective data. 6. The correct answer is d since the person has the right to indicate who he would like to be present for the history and examination. You should neither presume that he wants his wife there ( a ), nor that he does not want her there ( c ). Similarly, the choice belongs to the person, not the wife ( b ). 7. The correct answer is d since it is now common policy not to use family members as interpreters. The son may not adequately translate medical information, may not be trusted to translate what is said without introducing his bias, and it may not be culturally sensitive to the person for him to serve in this capacity. Answer a is incorrect as policy prohibits family members from translating, ( b ) is incomplete and ( c ) also contravenes policy. 8. The correct answer is c . You should first validate your finding if it is unusual, deviates from normal and is

unsupported by other data. Should your initial recording prove to be in error, it would have been premature to notify the charge nurse/midwife ( a ) or the surgeon ( b ). You want to be sure that all data you record are accu- rate, so it should be validated before documentation if you have doubts ( d ). 9. The correct answer is a . Your facilitator is most likely to challenge your inference that the person is ‘fine’ simply because she is telling you that she has no problems. It is appropriate for your facilitator to ask how you validated this inference. Jumping to the conclusion that the person does not trust you ( b ) is premature and is an invalidated inference. Answer c is incorrect because it accepts your invalidated inference and d is wrong because it is possi- ble that the condition is resolving. Alfaro-LeFevre, R. (2013). Applying nursing process: The foundation for clinical reasoning (8th ed.). Philadelphia: Lippincott Williams & Wilkins. Bickley, L. (2013). Bates’ pocket guide to physical examination and history taking (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Chenoweth, L., Jeon, Y.H., Goff, M. & Burke, C. (2006). Cultural competency and nursing care: An Australian perspective. International Nursing Review, 53(1), 34–40. Gordon, M. (2010). Manual of nursing diagnosis (12th ed.). Jones and Bartlett Publishers International. Jarvis, C. (2012). Physical examination and health assessment (7th ed.). St Louis: Saunders Elsevier. King, L. & Appelton, J.V. (1997). Intuition: A critical review of the research and rhetoric. Journal of Advanced Nursing , 26, 194–202. Kleiman, S., Frederickson, K. & Lundy, T. (2004). Using an eclectic model to educate students about cultural influences on the nurse– patient relationship. Nursing Education Perspectives , 25(5), 249–252. Lafluer, K.J. (2004). Taking the fifth [vital sign]. RN , 67(7), 30–37. Lewis, P. & Foley, D. (2011). Weber & Kelley’s health assessment in nursing (1st Australian & New Zealand ed.). Sydney: Lippincott Williams & Wilkins. Maslow, A. (1943). A theory of human motivation, Psychological Review , 50, 370–396. Bibliography