Chapter 15: Critical Thinking in Nursing Practice (Fundamentals)

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Critical Thinking Skill – Interpretation
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Be orderly in data collection. Look for patterns to categorize data and clarify any data you are uncertain about
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Critical Thinking Skill – Analysis
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Be open-minded as you look at information about a patient. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options?
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Critical Thinking Skill – Inference
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Look at the meaning and significance of findings. Are there relationships between findings? Do the data about the patient help you see that a problem exists?
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Critical Thinking Skill – Evaluation
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Look at all situations objectively. Use criteria (such as expected outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect on your own behavior.
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Critical Thinking Skill – Explanation
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Support your findings and conclusions. Use knowledge and experience to choose strategies to use in the care of patients.
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Critical Thinking Skill – Self-regulation
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Reflect on your experiences. Identify the ways you can improve your own performance. What will make you believe that you have been successful?
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Critical Thinking Behavior – Truth Seeking
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Seek the true meaning of a situation. Be courageous, honest, and objective about asking questions.
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Critical Thinking Behavior – Open-mindedness
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Be tolerant of different views; be sensitive to the possibility of your own prejudices; respect the right of others to have different opinions.
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Critical Thinking Behavior – Analyticity
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Analyze potentially problematic situations; anticipate possible results or consequences; value reason; use evidence-based knowledge.
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Critical Thinking Behavior – Systematicity
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Be organized, focused; work hard in any inquiry.
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Critical Thinking Behavior – Self-confidence
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Trust in your own reasoning processes.
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Critical Thinking Behavior – Inquisitiveness
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Be eager to acquire knowledge and learn explanations even when applications of the knowledge are not immediately clear. Value learning for learning’s sake.
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Critical Thinking Behavior – Maturity
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Multiple solutions are acceptable. Reflect on your own judgments; have cognitive maturity.
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Critical Thinking Attitudes – Confidence
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Learn how to introduce yourself to a patient; speak with conviction; do not lead a patient to think that you are unable to perform care safely; always be prepared; encourage patient to ask questions.
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Critical Thinking Attitudes – Thinking Independently
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Read nursing literature, especially when there are different views on the subject; talk with other nurses and share ideas on nursing interventions
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Critical Thinking Attitudes – Fairness
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Listen to both sides of discussion; if staff member labels a patient uncooperative, assume the care of that patient with openness and a desire to meet that patient’s needs.
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Critical Thinking Attitudes – Responsibility and authority
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Ask for help when uncertain how to perform a nursing skill; refer to a policy and procedure manual to review steps of a specific skill; report any problems immediately; follow standards of practice in your care.
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Critical Thinking Attitudes – Risk taking
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If your knowledge causes you to question a health care provider’s order, do so. Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patients.
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Critical Thinking Attitudes – Discipline
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Be thorough in whatever you do. use known scientific and practice-based criteria for activities such as assessment and evaluation. Take time to be thorough and manage time effectively.
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Critical Thinking Attitudes – Perseverance
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Be cautious of an easy answer. If facts or information about a patient seem to be missing, clarify the information with co-worker or talk to patient directly. If problems of the same type seem to be occurring on a nursing division, bring co-workers together, look for a pattern, and find a solution.
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Critical Thinking Attitudes – Creativity
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Look for different approaches if interventions are not working for a patient (moving patient positions or use different distraction technique). When appropriate, involve the patient’s family in adapting your approaches to care methods used at home.
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Critical Thinking Attitudes – Curiosity
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Always ask why. A clinical sign or symptom often indicates a variety of problems. Explore and learn more about the patient so as to make appropriate clinical judgments.
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Critical Thinking Attitudes – Integrity
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Recognize when your opinions conflict with those of a patient; review your position, and decide how best to proceed to reach outcomes that will satisfy everyone. Do not compromise nursing standards or honest in delivering nursing care.
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Critical Thinking Attitudes – Humility
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Recognize when you need more information to make a decision. When you are new to a clinical division, ask for an orientation to the area. Ask RNS regularly assigned to the area for assistance with approaches to care.
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General Critical Thinking – Problem Solving
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obtain information and use it, plus what you already know, to find a solution; to be effective, you must evaluate the solution over time to make sure that it is effective.
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General Critical Thinking – Decision Making
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product of critical thinking that focuses on problem resolution and choses a course of action; follow a set of criteria that can be personal, based on an organizational policy, or a professional standard
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General Critical Thinking – Decision Making
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recognize and define the problem or situation; assess all options; weigh each option against a set of personal criteria; test possible options; consider the consequences or pros and cons; select course of action
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Specific Critical Thinking – Diagnostic Reasoning
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analytical process for determining a patient’s health problems; expert nurse sees the context of a patient situation, observes patterns and themes, logically recognizes problems and makes decisions quickly
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Specific Critical Thinking – Clinical Inference
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process of drawing conclusions from related pieces of evidence and previous experience with evidence; involves forming patterns of information from data before making a diagnosis
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Specific Critical Thinking – Clinical Decision Making
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requires careful reasoning and knowing your patients which leads to pattern recognition of patient symptoms and responses; always keep the patient center of focus; do not assume that certain health situations produce automatic priorities
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Nursing Process
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Assessment, Diagnosis, Planning, Implementation, and Evaluating
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Human Responses
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include patient symptoms and physiological reactions to treatment, the need for knowledge when health care providers make a new diagnosis or treatment plan, and a patient’s ability to cope with loss
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Five components of critical thinking
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-knowledge base -experience -critical thinking competencies (with emphasis on the nursing process) -attitudes -standards
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Five-step nursing process model
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defines the outcome of critical thinking: nursing judgment that is relevant to nursing problems in a variety of settings
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Specific knowledge base
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prepares you to better anticipate and identify patients’ problems by understanding their origin and nature; offers physical, psychological, social, moral, ethical, and cultural view of patients and their health care needs
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Experience
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necessary to acquire clinical decision-making skills; becomes stepping-stones for building new knowledge and inspiring innovative thinking
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Nursing process competency
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relationship of critical thinking to the nursing process is emphasized
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Attitudes of critical thinking
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involve an ability to recognize that problems exist and that there is a need for evidence to support the truth in what you think is true; guidelines for how to approach a problem or decision-making situation
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Intellectual standards for critical thinking
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guideline or principle for rational thought; thorough use of in clinical practice makes certain that you do not perform critical thinking haphazardly; there are 14
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Professional standards for critical thinking
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ethical criteria for nursing judgments, evidence-based criteria used for evaluation, and criteria for professional responsibility; focus on patient’s values and beliefs, maintain a sense of self-awareness, use evidence-based criteria for making clinical judgments
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While assessing a patient, the nurse observes that the patient’s intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient’s skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of:
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1 Inference. 2 Diagnostic reasoning. 3 Competency. 4 Problem solving Answer: 4
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The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can’t concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of:
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1 Diagnostic reasoning. 2 Competency. 3 Inference. 4 Problem solving Answer: 1
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A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff respond, but the patient dies 30 minutes later. The manager on the nursing unit calls the staff involved in the emergency response together. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. The nurses in this situation are:
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1 Problem solving. 2 Showing humility. 3 Conducting reflective practice. 4 Exercising responsibility Answer: 3
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A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, “I feel funny.” The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, “I believe that your patient is developing sepsis. I want to report symptoms I’m seeing.” What examples of critical thinking concepts does the nurse show? (Select all that apply.)
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1 Experience 2 Ethical 3 Analyticity 4 Self-confidence 5 Risk taking Answer: 3 and 4
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A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent(s) use of clinical decision making for groups of patients? (Select all that apply.)
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1 Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction. 2 Think about past experience with patients who develop postoperative complications. 3 Decide which activities can be combined for patients B and C. 4 Carefully gather any assessment information and identify patient problems. Answer: 1 and 3
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The surgical unit has initiated the use of a pain-rating scale to assess patients’ pain severity during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard?
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1 Deep 2 Relevant 3 Consistent 4 Significant Answer: 3
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During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient’s home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, “This hurts too much. I don’t see why I have to do this so many times.” The nurse applies the critical thinking attitude of integrity in which of the following actions?”
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1 “I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let’s go a bit more slowly and try to relax.” 2 “I see that you’re uncomfortable. I’ll call your doctor to decide the next step.” 3 “Show me exactly where your pain is and rate it for me on a scale of 0 to 10.” 4 “Is anything else bothering you? Other than the pain, is there any other reason you might not want to do the exercises?” Answer: 1
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The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The health care team tried for 45 minutes to resuscitate the child with no success. The family was devastated by the loss, and, when the nurse tried to talk with them, the mother said, “You can’t make me feel better; you don’t know what it’s like to lose a child.” Which of the following examples of journal entries might best help the nurse reflect and think about this clinical experience? (Select all that apply.)
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1 Data entry of time of day, who was present, and condition of the child 2 Description of the efforts to restore the child’s blood pressure, what was used, and questions about the child’s response 3 The meaning the experience had for the nurse with respect to her understanding of dealing with a patient’s death 4 A description of what the nurse said to the mother, the mother’s response, and how the nurse might approach the situation differently in the future Answer: 2, 3, and 4
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A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is:
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1 Commitment. 2 Scientific method. 3 Basic critical thinking. 4 Complex critical thinking. Answer: 3
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A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device for an 8-hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of:
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1 Planning. 2 Evaluation. 3 Intervention. 4 Diagnosis Answer: 2
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A 67-year-old patient will be discharged from the hospital in the morning. The health care provider has ordered three new medications for her. Place the following steps of the nursing process in the correct order.
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1 The nurse returns to the patient’s room and asks her to describe the medicines she will be taking at home. 2 The nurse talks with the patient and family about who will be available if the patient has difficulty taking medicines and considers consulting with the health care provider about a home health visit. 3 The nurse asks the patient if she is in pain, feels tired, and is willing to spend the next few minutes learning about her new medicines. 4 The nurse brings the containers of medicines and information leaflets to the bedside and discusses each medication with her. 5 The nurse considers what she learns from the patient and identifies the patient’s nursing diagnosis. Answer: 3 (assessment) 5 (nursing diagnosis) 2 (planning) 4 (intervention) 1 (evaluation)
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The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description of loss and grief and therapeutic communication principles in his textbook. The critical thinking component involved in the nurse’s review of the literature is:
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1 Experience. 2 Problem solving. 3 Knowledge application. 4 Clinical decision making Answer: 3
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A nurse is working with a nursing assistive personnel (NAP) on a busy oncology unit. The nurse has instructed the NAP on the tasks that need to be performed, including getting patient A out of bed, collecting a urine specimen from patient B, and checking vital signs on patient C, who is scheduled to go home. Which of the following represent(s) successful delegation? (Select all that apply.)
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1 A nurse explains to the NAP the approach to use in getting the patient up and why the patient has activity limitations. 2 A nurse is asked by a patient to help her to the bathroom; the nurse leaves the room and directs the NAP to assist the patient instead. 3 The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early. 4 The nurse is in patient B’s room to check an intravenous (IV) line and collects the urine specimen while in the room. 5 The nurse offers support to the NAP when needed but allows her to complete patient care tasks without constant oversight. Answer: 1, 3, and 4
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Which of the following is unique to the commitment level of critical thinking?
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1 Weighs benefits and risks when making a decision. 2 Analyzes and examine choices more independently. 3 Concrete thinking. 4 Anticipates when to make choices without others’ assistance Answer: 4
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In which of the following examples is the nurse not applying critical thinking skills in practice?
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1 The nurse considers personnel experience in performing intravenous (IV) line insertion and ways to improve performance. 2 The nurse uses a fall risk inventory scale to determine a patient’s fall risk. 3 The nurse observes a change in a patient’s behavior and considers which problem is likely developing. 4 The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care. Answer: 4
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Reflection
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process of purposefully thinking back or recalling a situation to discover its purpose or meaning; honestly review everything
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Reflective practice
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conscious process of thinking, analyzing, and learning from your work situations by way of journaling or regularly meeting with colleagues to explore work situations and self-evaluate
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Reflective journaling
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tool for developing critical though and reflection by clarifying concepts; gives opportunity to define and express the clinical experience in your own words
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Concept mapping
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visual representation of patient problems and interventions that shows their relationships to one another; learn to organize or connect information to form meaningful patterns
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Levels of critical thinking
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-Basic -Complex -Commitment
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1-Basic level of critical thinking
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concrete thinking based on a set of rules or principles; answers to complex problems are either right or wrong
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2-Complex level of critical thinking
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analyze and examine choices by weighing the benefits and consequences of each solution; thinking is creative and innovative
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3-Commitment level of critical thinking
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anticipates when to make choices, considers results of decision and accepts responsibility for decision made
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Intellectual standards for critical thinking
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clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for purpose), fair
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Professional standards for critical thinking
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ethical criteria for nursing judgment, criteria for evaluation, professional responsibility

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