3. The nurse identifies that a patient on prolonged bed rest may be developing a pres- sure ulcer when the skin over a bony prominence appears:
1. Red 2. Blue 3. Black 4. Yellow
CHAPTER1 FUNDAMENTALS OFCRITICALTHINKINGRELATED TOTESTTAKING 23
CRITICAL-THINKING STRATEGY
Recognize keywords.
Recognize who the client is.
Ask what the question is asking.
Critically analyze options in relation to the question.
Eliminate incorrect options.
The nurse identifies that a patient may be developing a pressure ulcerwhen the skinover a bony prominenceappears:
The patient is the client.
Which early sign indicates a pressure ulcer caused by immobility?
The words in the stem that indicate this is an applica- tion question are identifiesand developing pressure ulcer.
To answer this question you have to understand how and why pressure can cause a pressure ulcer and know the common early sign that indicates the for- mation of a pressure ulcer.
Although it is helpful to know what is happening when the skin reflects each of the colors indicated so that you can eliminate incorrect answers, it is not neces- sary to comprehend this information to answer the question.
Rationales:
1. Erythema is a red discoloration generally caused by local vasodilation in an attempt to bring more oxygen to the area.
2. Cyanosis is a bluish color caused by an increased amount of deoxygenated hemoglobin associated with hypoxia not pressure.
3. Eschar generally appears black and is the scab or dry crust that results from death of tissue.
4. Jaundice is a yellow-orange color caused by increased deposits of bilirubin in tissue, not a response to pressure.
Options 2, 3, and 4 are not early signs of a pressure ulcer and are incorrect answers. They can be eliminated.
Beginning nursing students find analysis-level questions the most difficult to answer.
Analysis questions demand scrutiny of individual elements of information as well as re- quire identification of differences among elements of information. Sometimes students cannot identify the structural or organizational relationship of elements of information.
The challenge of answering analysis questions is performing a complete scrutiny of all the various elements of information and their interrelationships without overanalyzing or
“reading into” the question. See TEST SUCCESS: Test-Taking Techniques for Beginning Nursing Studentsfor specific study techniques related to analysis-level questions.
U
SE AC
RITICAL-T
HINKINGS
TRATEGY TOA
NSWERA
NALYSIS-L
EVELQ
UESTIONS1. A frail, malnourished older adult has been experiencing constipation. Which medica- tion does the nurse anticipate that the practitioner will most likely prescribe?
1. Bisacodyl (Dulcolax) 2. Docusate sodium (Colace) 3. Mineral oil (Haley’s M-O)
4. Magnesium hydroxide (milk of magnesia [MOM])
24 FUNDAMENTALSSUCCESS: A Q & A REVIEWAPPLYINGCRITICALTHINKING TOTESTTAKING
CRITICAL-THINKING STRATEGY
Recognize keywords.
Recognize who the client is.
Ask what the question is asking.
Critically analyze options in relation to the question.
A frail, malnourished older adulthas been experienc- ing constipation. What medication does the nurse anticipate that the practitioner will most likely prescribe?
The patient is the client.
Which medication that promotes defecation is least likely to cause problems in a debilitated older adult?
Analysis questions often ask you to set priorities as in- dicated by the words most likely orderin the stem of this question.
This question requires you to: understand that frail, malnourished older adults have minimal compensa- tory reserve in various body systems to manage responses to cathartics and laxatives; know the physiological action, outcome, side effects, and toxic effects of all four medications presented in the stem; contrast and compare the drugs and the risks they pose in the older adult to arrive at which drug would be the least risky drug. The least risky drug is the one the practitioner is most likely to order.
Rationales:
1. Dulcolax irritates the intestinal mucosa, stimulates nerve endings in the wall of the intestines, and causes rapid propulsion of waste from the body.
Dulcolax is not the best choice of a laxative for an older adult because it can cause intestinal cramps, fluid and electrolyte imbalances, and irritation of the intestinal mucosa.
2. Colace permits fat and water to penetrate feces, which soften stool. Of all the options, Colace has the fewest side effects in older adults.
3. Mineral oil lubricates feces in the colon; however, it can inhibit the absorption of fat-soluble vitamins and is not the best laxative for an older adult.
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CHAPTER1 FUNDAMENTALS OFCRITICALTHINKINGRELATED TOTESTTAKING 25
Eliminate incorrect options.
Continued
4. Milk of magnesia (MOM) draws water into the in- testine by osmosis, which stimulates peristalsis.
It is contraindicated for an older adult because it can cause fluid and electrolyte imbalances and inhibit absorption of fat-soluble vitamins.
Options 1, 3, and 4 are more potent than the correct answer and therefore are least likely to be ordered to relieve constipation in a debilitated older adult.
2. The mother of a terminally ill child says, “I never thought that I would have such a sick child.” What is the best initial response by the nurse?
1. “How do you feel right now?”
2. “What do you mean by sick child?”
3. “Life is not fair to do this to a child.”
4. “It’s hard to believe that your child is so sick.”
CRITICAL-THINKING STRATEGY
Recognize keywords.
Recognize who the client is.
Ask what the question is asking.
Critically analyze options in relation to the question.
Eliminate incorrect options.
The mother of a terminally ill child says, “I never thought that I would have such a sick child.”What is the best initial response by the nurse?
The mother is the client.
Which is an example of the best interviewing skill to use when initially responding to a statement made by the mother of a sick child?
Analysis questions often ask you to set priorities as in- dicated by the words best initial responsein the stem of this question.
To answer this question you need to: identify which interviewing techniques are portrayed in the state- ments in each option; understand how and why each interviewing skill works; compare and contrast the pros and cons of each technique if used in this situ- ation; and identify which technique is the most sup- portive, appropriate, and best initial response by the nurse.
Rationales:
1. Direct questions cut off communication and should be avoided.
2. This response focuses on the seriousness of the child’s illness, which is not the issue raised in the mother’s statement.
3. This statement reflects the beliefs and values of the nurse, which should be avoided.
4. This is a declarative statement that paraphrases the mother’s beliefs and feelings. It communicates to the mother that the nurse is attentively listening and invites the mother to expand on her thoughts if she feels ready.
Options 1, 2, and 3 can be eliminated because they do not focus on the content of the mother’s statement.
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3. Which patient has the greatest risk for developing a pressure ulcer?
1. An older adult on bed rest 2. A toddler learning to walk 3. A thin young woman in a coma
4. An emotionally unstable middle-aged man
26 FUNDAMENTALSSUCCESS: A Q & A REVIEWAPPLYINGCRITICALTHINKING TOTESTTAKING
CRITICAL-THINKING STRATEGY
Recognize keywords.
Recognize who the client is.
Ask what the question is asking.
Critically analyze options in relation to the question.
Eliminate incorrect options.
Which patient has the greatest riskfor developinga pressure ulcer?
The patient is the client.
Which patient in the various age groups is at the greatest risk for a pressure ulcer?
Analysis questions often ask you to set priorities as in- dicated by the words greatest riskin the stem of this question.
To answer this question you need to: know what are the major risk factors that contribute to the develop- ment of a pressure ulcer; identify the risk factors for pressure ulcer development in all four of the specific categories of the life span represented in the op- tions; and assign a level of risk to each of the indi- viduals identified in the options in comparison with each of the other individuals. Once you complete this intellectual analysis, you will identify the indi- vidual at greatest risk.
Rationales:
1. Although the skin of older adults is vulnerable to the development of pressure ulcers because of de- creased subcutaneous fat, reduced thickness and vascularity of the dermis, and decreased sebaceous gland activity, older adults are still capable of changing position and moving around in bed, which relieves pressure on integumentary tissue.
2. A toddler learning to walk is not immobile. In addition, the skin of toddlers usually has adequate circulation, subcutaneous tissue, and hydration and is supple. A toddler may fall and develop bruises (contusions) or scrapes (abrasions), not pressure ulcers.
3. Of the options offered, this person is the most vulnerable for developing a pressure ulcer. A thin person has little protective subcutaneous fat over bony prominences, and a person in a coma is immobile and unable to move or turn purposefully.
Immobility results in prolonged pressure, which interferes with the oxygen supply to body cells.
4. Middle-aged men usually do not exhibit the effects of aging on the integumentary system. In addition, emotionally unstable people are able to move and change positions, which permits circulation to the cells of the skin.
Individuals presented in options 1, 2, and 4 are at less of a risk than a thin person who is immobile for the development of pressure ulcers.
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