A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice
Question:
A nurse is caring for a client who reports dizziness shortly after
receiving a newly prescribed medication. Which action best
reflects the Recognize Cues step of the Clinical Judgment
Measurement Model (CJMM)?
A. Lower the medication dose immediately
B. Identify the dizziness as important clinical information
C. Determine the most likely cause of the dizziness
D. Evaluate whether the intervention was effective
Correct Answer: B
Rationale: Recognizing cues involves identifying relevant
assessment findings. The nurse first notices and collects
information before analyzing causes or implementing
interventions.
Question 2
,Difficulty: Moderate
Question Type: Multiple Choice
Question:
A nurse notes that a client receiving an opioid has a respiratory
rate of 8 breaths/minute and oxygen saturation of 88%. Which
CJMM step is demonstrated when the nurse determines that
opioid-induced respiratory depression is the most likely
explanation?
A. Recognize Cues
B. Analyze Cues
C. Take Action
D. Evaluate Outcomes
Correct Answer: B
Rationale: Analyzing cues involves interpreting assessment data
and identifying relationships among findings to determine likely
clinical problems.
Question 3
Difficulty: Moderate
Question Type: SATA
Question:
, The nurse is assessing a client before administering a scheduled
antihypertensive medication. Which findings are important cues
that should be recognized? Select all that apply.
A. Blood pressure 88/54 mm Hg
B. Reports dizziness when standing
C. Heart rate 52 beats/minute
D. Favorite television program
E. Recent fall at home
Correct Answer: A, B, C, E
Rationale: Hypotension, dizziness, bradycardia, and a history of
falls are clinically relevant cues affecting medication safety. A
television preference is not relevant to medication
administration.
Question 4
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
A client receiving intravenous antibiotics develops a widespread
rash and reports throat tightness. What should the nurse
prioritize?