A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: Multiple Choice (MCQ)
Question:
A nurse is caring for a client who received a first dose of an
antihypertensive medication. Thirty minutes later, the client
reports dizziness when standing. Which nursing action best
demonstrates the Recognize Cues step of the Clinical Judgment
Measurement Model (CJMM)?
A. Assist the client back to bed and notify the provider
immediately.
B. Measure the client's blood pressure while lying and standing.
C. Document that orthostatic hypotension has occurred.
D. Teach the client to rise slowly from bed.
Correct Answer: B
Rationale:
Recognizing cues involves collecting relevant assessment data
before making clinical decisions. Measuring orthostatic blood
pressure provides objective information needed to determine
whether the medication caused hypotension.
,Question 2
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)
Question:
A client receiving intravenous morphine becomes difficult to
arouse and has a respiratory rate of 8 breaths/min. Which
action represents Analyze Cues?
A. Administer naloxone.
B. Determine that opioid-induced respiratory depression is the
most likely cause.
C. Place the client on continuous pulse oximetry.
D. Educate the client about opioid adverse effects.
Correct Answer: B
Rationale:
Analyzing cues requires interpreting assessment findings to
identify the most likely clinical problem. Determining that
respiratory depression is related to opioid therapy guides
subsequent interventions.
Question 3
Difficulty: Moderate
, Question Type: Select All That Apply (SATA)
Question:
A nurse is caring for a client who received insulin. Which
assessment findings should the nurse recognize as cues
suggesting hypoglycemia?
Select all that apply.
A. Diaphoresis
B. Tremors
C. Blood glucose of 52 mg/dL
D. Warm, flushed skin
E. Confusion
Correct Answers: A, B, C, E
Rationale:
Common cues of hypoglycemia include sweating, tremors,
confusion, and a low blood glucose level. Warm, flushed skin is
not a typical finding.
Question 4
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question: