uUNIT III

Integrated Processes

7 Integrated Processes and the NCLEX-RNW Test Plan 476

Test 5 Integrated Processes 481

475

uCHAPTER

7Integrated Processes and theNCLEX-RN‚ Test Plan

INTEGRATED PROCESSES

In the new test plan implemented in April 2010, the NationalCouncil of State Boards of Nursing (NCSBN) identified a testplan framework based on Client Needs. This framework wasselected on the basis of the analysis of the findings in a practiceanalysis study of newly licensed registered nurses in the UnitedStates. This study identified the nursing activities performedby entry-level nurses across all settings for all clients. TheNCSBN identified four major categories of Client Needs. Thesecategories—Safe and Effective Care Environment, HealthPromotion and Maintenance, Psychosocial Integrity, andPhysiological Integrity—are described in Chapter 6.

The 2010NCLEX-RN test plan also identifies four processesthat are fundamental to the practice of nursing. These processesare integrated throughout the four major categories of ClientNeeds. The test plan for NCLEX-RN identifies these compo-nents as Integrated Processes, and they are as follows: Caring,Communication and Documentation, Teaching and Learning,and Nursing Process (Box 7-1).

CARING

Caring is the essence of nursing, and it is basic to any helpingrelationship. Caring is central to every encounter that a nursemay have with a client. Through caring, the nurse humanizesthe client. Treating the client with respect and dignity is a trueexpression of caring. In the technological environment ofhealth care, emphasizing the client’s individuality counter-acts any potential process of depersonalization. Caring isan Integrated Process of the test plan for NCLEX-RN andthe NCSBN describes caring in part as a role of the nurse inproviding encouragement, hope, support, and compassion.The process of caring is nuclear to all Client Needs compo-nents of the test plan.

For the NCLEX-RN, the process of caring is primary. It isvery easy to become involved with looking at a question froma technological viewpoint. However, the process of caringmustbe addressed when reading a test question and when selectingan option. Always address the client’s feelings and provide

support. Remember that this examination is all about nursing,and nursing is caring (Box 7-2)!

COMMUNICATION AND DOCUMENTATION

The process of communication occurs as a nurse interactseither verbally or nonverbally with a client. Therapeutic com-munication techniques are essential to an effective nurse–clientrelationship. Communication-type test questions are inte-grated throughout the NCLEX-RN test plan, and they mayaddress a client situation in any health care setting. TheNCSBNdescribes communication as the verbal and nonverbal inter-actions that occur in the health care environment.

When answering a question on the NCLEX-RN, the use oftherapeutic communication techniques indicates a correct

tBox 7-1 Integrated Processes

CaringCommunication and DocumentationTeaching and LearningNursing Process

tBox 7-2 Caring

A client who has end-stage cancer is admitted to a hospice carefacility from her home. Which intervention should the nurse imple-ment to address the client’s psychosocial needs?

1. Administer total care for the client.2. Engage the client in social activities.3. Allow the client to verbalize feelings.4. Provide pain medication every 4 hours.

Answer: 3

Rationale:The client is experiencing loss from two life-changing experiences:her poor prognosis and the loss of control over the environment,independence, and privacy that accompanies admission to a hos-pice care facility. To meet the client’s psychosocial needs, thenurse should promote a therapeutic relationship and allow the cli-ent to verbalize her feelings. Options 1 and 4 manage physicalneeds. Although total care may be necessary, it does not addresspsychosocial needs. Providing pain medication is indicated as partof effective painmanagement; however, this can interfere with ther-apeutic communication if the client is too sedated. Engaging theclient in social activities is unlikely to effectively meet the client’spsychosocial needs relating to loss; it is more likely to help dimin-ish loneliness and isolation.

ReferencesBlack, J., & Hawks, J. (2009).Medical-surgical nursing: Clinical management

for positive outcomes (8th ed.). St. Louis: Saunders.

Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Camera, I. (2011).

Medical-surgical nursing: Assessment and management of clinical

problems (8th ed.). St. Louis: Mosby.

Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.). St. Louis:

Mosby.

476

option, and the use of nontherapeutic communication tech-niques indicates an incorrect option. In additional, somecommunication-type questions may focus on psychosocialissues or issues related to client anxiety, fears, or concerns.For communication-type questions, always focus on theclient’s feelings first. If an option reflects the client’s feelings,anxiety, or concerns, select that choice.

Documentation is a critical component of a nurse’s respon-sibilities. The process of documentation serves many purposes;it provides a comprehensive representation of the client’shealth status and the care given by all members of the healthcare team. There are many methods of documentation, butthe responsibilities surrounding this practice remain the same.The NCSBN describes documentation as the activities associ-ated with the client’s medical record that reflect standards ofpractice and accountability.

When answering a question on the NCLEX-RN related todocumentation, consider the ethical and legal responsibilitiesrelated to documentation and the specific guidelines relatedto both narrative and computerized documentation systems(Box 7-3).

TEACHING AND LEARNING

Client and family education is a primary nursing responsibil-ity. The NCSBN describes this process as facilitating the acqui-sition of knowledge, skills, and attitudes that lead to a changein behavior.

The principles related to the teaching and learning process areused when the nurse functions as a teacher. The nurse must re-member that the assessment of the client’s readiness andmotiva-tion to learn is the initial step in the teaching and learningprocess.

When answering a question on the NCLEX-RN related tothe teaching and learning process, use the principles related

to teaching and learning theory. If a test question addresses cli-ent education, remember that client motivation and readinessto learn is the first priority (Box 7-4).

NURSING PROCESS

The steps of the nursing process provide a systematic and orga-nizedmethod of problem solving and providing care to clients.As noted by the NCSBN, the steps include assessment, analysis,planning, implementation, and evaluation (Box 7-5).

tBox 7-3 Communication and Documentation

CommunicationA client with myasthenia gravis is having difficulty with the motor as-pects of speech. The client has difficulty forming words, and the voicehas a nasal tone. The nurse should plan to use which communicationstrategy when working with this client?

1. Encourage the client to speak quickly.2. Nod continuously while the client is speaking.3. Repeat what the client has said to verify the message.4. Engage the client in lengthy discussions to strengthen the

voice.

Answer: 3

Rationale:The client has speech that is nasal in tone because of cranial nerveinvolvement in the muscles that govern speech. The nurse should lis-ten attentively and verbally verify what the client has said. Other help-ful techniques involve asking questions that require a “yes” or “no”response and developing alternative communication methods (e.g.,letter board, picture board, pen and paper, flash cards). Encouragingthe client to speak quickly is inappropriate and counterproductive.Continuous nodding may be distracting and is unnecessary. Lengthydiscussions will tire the client rather than strengthen the voice.

ReferenceIgnatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-

centered collaborative care (6th ed.). St. Louis: Saunders.

DocumentationThe nurse finds a client lying on the floor. The nurse performs an as-sessment, assists the client back to bed, and completes an incidentreport. Which should the nurse document on the incident report?

1. The client fell onto the floor.2. The client climbed over the side rails.3. The client was found lying on the floor.4. The nurse was the only responder to the event.

Answer: 3

Rationale:The incident report should contain the client’s name, age, anddiagnosis as well as a factual description of the incident, any injuriesexperienced by those involved, and the outcome of the situation.Option 3 is the only choice that describes the facts as observed bythe nurse. The nurse did not witness the events that led up to findingthe client on the floor; thus he or she cannot comment on how theclient got to the floor (options 1 and 2). Option 4 is unsuitable docu-mentation on an incident report, because it implies that other staffmembers failed to respond to the event.

ReferencesHuber, D. (2010). Leadership and nursing care management (4th ed.).

St. Louis: Saunders.

Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.). St. Louis:

Mosby.

tBox 7-4 Teaching and Learning

A nurse is preparing a plan regarding home care instructions for theparents of a child with generalized tonic-clonic seizures who isbeing treated with oral phenytoin (Dilantin). The nurse includesinstructions in the plan regarding:

1. Monitoring the child’s intake and output daily2. Providing oral hygiene, especially care of the gums3. Administering the medication 1 hour before food intake4. Checking the child’s blood pressure before the administra-

tion of the medication

Answer: 2

Rationale:Phenytoin is an anticonvulsant medication and causes gum bleed-ing and hyperplasia; therefore a soft toothbrush and gummassageshould be instituted to diminish this complication and preventtrauma. Intake, output, and blood pressure are not affected by thismedication. Directions for administration of this medication in-clude administering it with food to minimize gastrointestinal upset.

ReferenceMcKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child

nursing (3rd ed.). St. Louis: Elsevier.

s477CHAPTER 7 Integrated Processes and the NCLEX-RN‚ Test Plan

Assessment

Assessment is the first step of the nursing process. It involves asystematic method of collecting data about a client to identifyactual and potential client health problems and establish a da-tabase. The database provides the foundation for the remain-ing steps of the nursing process; therefore, a thorough andadequate database is essential. Data collection begins withthe first contact with the client. During all successive contacts,the nurse continues to collect information that is significantand relevant to the needs of that client.

During the assessment process, the nurse collects dataabout the client from a variety of sources. The client is the pri-mary source of data. Familymembers and significant others aresecondary sources of assessment data, and these sources maysupplement or verify the information provided by the client.Data may also be obtained from the client’s record throughthe medical history, laboratory results, and diagnostic reports.Medical records from previous admissions may provide addi-tional information about the client. The nurse may also obtaininformation through consultation with other health care teammembers who have had contact with the client.

A thorough database is obtained with the use of a healthhistory and a physical assessment. The information collectedby the nurse includes both subjective and objective data.Subjective data include the information that the client states.Objective data are the observable, measurable pieces of infor-mation about the client, including measurements such as vitalsigns and laboratory findings, as well as information obtainedby observing the client. Objective data also include clinicalmanifestations, such as the signs and symptoms of an illnessor disease.

The process of assessment additionally consists of confirm-ing and verifying client data, communicating informationobtained through the assessment process, and documentingassessment findings in a thorough and accurate manner.

On the NCLEX-RN, remember that assessment is the firststep of the nursing process. When answering these types ofquestions, focus on the data in the question, and select theoption that addresses an assessment action. In addition, usethe skills of prioritizing and the ABCs—airway, breathing,and circulation—to answer the question (Box 7-6).

Analysis

Analysis is the second step of the nursing process. During thisstep, the nurse focuses on the data gathered during the assess-ment process and identifies actual or potential health careneeds, problems, or both. During this process, the nurse sum-marizes and interprets the assessment data, organizes and val-idates the data, and determines the need for additional data.Client assessment data are compared with the normal expectedfindings and behaviors for the client’s age, education, and

cultural background. The nurse then draws conclusions regard-ing the client’s unique needs and health care risks or problems.

Client health problems are categorized as at-risk problemsthat require prevention or as actual problems that are beingmanaged or require interventions. The nurse reports the resultsof the analysis to the appropriate members of the health careteam and documents the client’s unique health care problems,needs, or both.

On the NCLEX-RN, questions that address the process ofanalysis are difficult, because they require an understandingof the principles of physiological responses as well as an inter-pretation of the data on the basis of assessment findings. Anal-ysis questions require critical thinking and determining therationale for therapeutic interventions that may be addressedin the case event. These questions may address the formulationof a nursing diagnosis and the communication and documen-tation of the results of the process of analysis (Box 7-7).

tBox 7-5 Steps of the Nursing Process

AssessmentAnalysisPlanningImplementationEvaluation

tBox 7-6 Nursing Process: Assessment

A clinic nurse in a well-baby clinic is collecting data regarding themotor development of a 15-month-old child. Which of the followingis the highest level of development that the nurse would expect toobserve in this child?

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.

Answer: 3

Rationale:At the age of 15 months, the nurse would expect that the childcould build a tower of two blocks. A 24-month-old child would beable to turn a doorknob and unzip a large zipper. At the age of30 months, the child would be able to put on simple clothesindependently.

ReferenceMcKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child

nursing (3rd ed.). St. Louis: Elsevier.

tBox 7-7 Nursing Process: Analysis

A client is admitted to the cardiac unit and placed on telemetry.A nurse reviews the client’s laboratory values and notes that thepotassium level is 6.3 mEq/L. When analyzing the cardiac rhythm,thenursewouldexpect tonotewhichelectrocardiogram(ECG) finding?

1. A sinus tachycardia with an extra U wave2. A sinus rhythm with a tall, peaked T wave3. A sinus rhythm with a depressed ST segment4. A sinus tachycardia with a prolonged QT interval

Answer: 2

Rationale:A potassium level of more than 5.1 mEq/L indicates hyperkalemia,which can be detected on ECG by the presence of a tall, peakedT wave. A U wave and a depressed ST segment are present withhypokalemia. A prolonged QT interval indicates hypocalcemia.

ReferenceIgnatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-

centered collaborative care (6th ed.). Philadelphia: Saunders.

s478 UNIT III Integrated Processes

Planning

Planning is the third step of the nursing process. This step in-volves the functions of setting priorities, determining goals ofcare, planning actions, collaborating with other health careteam members, establishing evaluative criteria, and communi-cating the plan of care.

Setting priorities assists the nurse with organizing and plan-ning care that solves the most urgent problems. Priorities maychange as the client’s level of wellness changes. Both actual andat-risk problems should be considered when establishing pri-orities. Actual problems are usually more important than at-risk problems. However, at-risk problems may at times takeprecedence over actual problems.

After priorities are established, the client and the nurse mu-tually decide on the expected goals. The selected goals serve as aguide for selecting nursing interventions and determining thecriteria for evaluation. Before nursing actions are implemen-ted, mechanisms to determine goal achievement and the effec-tiveness of nursing interventions are established. Unlesscriteria have been predetermined, it is difficult to knowwhether the goal has been achieved or the problem has beenresolved.

It is important for the nurse to both identify health or socialresources available to the client and collaborate with otherhealth care team members when planning the delivery of care.The nurse must communicate the plan of care, review the planof care with the client, and document the plan of care thor-oughly and accurately.

When answering questions on the NCLEX-RN, rememberthat this is a nursing examination. In addition, remember thatactual problems are usually more important than at-risk prob-lems, and physiological needs are usually the priority (Box 7-8).

Implementation

Implementation is the fourth step of the nursing process. It in-cludes initiating and completing nursing actions that are re-quired to accomplish defined goals. This step is the actionphase that involves counseling, teaching, organizing and

managing client care, providing care to achieve establishedgoals, supervising and coordinating the delivery of client care,and communicating and documenting the nursing interven-tions and client responses.

During implementation, the nurse uses intellectual, inter-personal, and technical skills. Intellectual skills involve criticalthinking, problem solving, and making judgments. Interper-sonal skills involve the ability to communicate, listen, and con-vey compassion. Technical skills relate to the performance oftreatments and procedures and the use of necessary equipmentwhen providing care to the client.

The nurse independently implements actions that includeactivities that do not require a physician’s prescription. Thenurse also implements actions collaboratively on the basis ofthe physician’s prescriptions. Sound nursing judgment andworking with other health care members is incorporated intothe process of implementation. The implementation step con-cludes when the nurse’s actions are completed and when theseactions, including their effects and the client’s response, arecommunicated and documented.

The NCLEX-RN is an examination about nursing, so focuson the nursing action rather than themedical action, unless thequestion is asking what prescribed medical action is antici-pated (Box 7-9).

Evaluation

Evaluation is the fifth and final step of the nursing process. Theprocess of evaluation identifies the degree to which the nursingdiagnoses, plans for care, and interventions have beensuccessful.

Although evaluation is the final step of the nursing process,it is an ongoing and integral component of each step. The pro-cess of data collection and assessment is reviewed to determineif sufficient information was obtained and the informationobtained was specific and appropriate. The nursing diagnosesare evaluated for accuracy and completeness on the basis of theclient’s specific needs. The plan and expected outcomes are ex-amined to determine whether they are realistic, achievable,

tBox 7-9 Nursing Process: Implementation

A nurse in the postpartum unit checks the temperature of a clientwho delivered a healthy newborn infant 4 hours ago. The mother’stemperature is 100.8� F. The nurse provides oral hydration to themother and encourages fluids. Four hours later, the nurse rechecksthe temperature and notes that it is still 100.8� F. Which nursingaction is appropriate?

1. Notify the physician.2. Document the temperature.3. Increase the intravenous fluids.4. Continue hydration and recheck the temperature 4 hours

later.

Answer: 1

Rationale:In the postpartum client, a temperature of more than 100.4� F attwo consecutive readings is considered febrile, and the physicianshould be notified. Options 2, 3, and 4 are inappropriate actionsat this time.

ReferenceMcKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child

nursing (3rd ed.). St. Louis: Elsevier.

tBox 7-8 Nursing Process: Planning

A nurse is planning care for a child with an infectious and commu-nicable disease. The nurse determines that the primary goal isthat:

1. The child will experience mild discomfort.2. The public health department will be notified.3. The child will not spread the infection to others.4. The child will experience only minor complications.

Answer: 3

Rationale:The primary goal for a child with an infectious and communicabledisease is to prevent the spread of the infection to others. It is alsoimportant for the nurse to prevent discomfort as much as possible.Although the health department may need to be notified at somepoint, it is not the primary goal. The child should experience nocomplications.

ReferenceHockenberry, M., & Wilson, D. (2009).Wong’s essentials of pediatric nursing

(8th ed.). St. Louis: Mosby.

s479CHAPTER 7 Integrated Processes and the NCLEX-RN‚ Test Plan

measurable, and effective. Interventions are examined to deter-mine their effectiveness for achieving the expected outcomes.

Because evaluation is an ongoing process, it is vital to allsteps of the nursing process. It is the continuous process ofcomparing actual outcomes with the expected outcomes ofcare, and it provides the means for determining the need tomodify the plan of care. Inherent in this step of the nursing

process are the communication of evaluation findings andthe process of documenting the client’s response to treatment,care, and teaching.

Evaluation-type questions on the NCLEX-RN may be writ-ten to address a client’s response to treatment measures or de-termine a client’s understanding of the prescribed treatmentmeasures (Box 7-10).

REFERENCESBlack, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical manage-

ment for positive outcomes (8th ed.). St. Louis: Saunders.

Hockenberry, M., & Wilson, D. (2009). Wong’s essentials of pediatricnursing (8th ed.). St. Louis: Mosby.

Hodgson, B., & Kizior, R. (2012). Saunders nursing drug handbook 2012.

St. Louis: Saunders.

Huber, D. (2010). Leadership and nursing care management (4th ed.).St. Louis: Saunders.

Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:

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.

McKinney, E., James, S., Murray, S., & Ashwill, J. (2009).Maternal-childnursing (3rd ed.). St. Louis: Elsevier.

National Council of State Boards of Nursing. (2010). 2010

NCLEX-RNW detailed test plan. Chicago: Author.

National Council of State Boards of Nursing. NCSBN Web Site:www.ncsbn.org Accessed 12.02.10.

Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed.).

St. Louis: Mosby.

tBox 7-10 Nursing Process: Evaluation

A client has been given a prescription for a course of azithromycin(Zithromax). The nurse determines that the medication is havingthe intended effect if which of the following is noted?

1. The pain is relieved.2. The blood pressure is lowered.3. The joint discomfort is reduced.4. The signs and symptoms of infection are relieved.

Answer: 4

Rationale:Azithromycin is amacrolide antibiotic that is used to treat infection.It is not prescribed for the treatment of pain, blood pressure, orjoint discomfort.

ReferenceHodgson, B., & Kizior, R. (2012). Saunders nursing drug handbook 2012.

St. Louis: Saunders.

s480 UNIT III Integrated Processes