A Patient-Centered Nursing
Process Approach
11th Edition
• Author(s)Linda McCuistion
TEST BANK
,Question 1
Difficulty: Easy
Question Type: MCQ
Question:
A nurse is caring for a client who reports dizziness shortly after
receiving a newly prescribed antihypertensive medication.
Which action represents the Recognize Cues (Assessment) step
of the Clinical Judgment Measurement Model (CJMM)?
A. Holding the next dose of the medication
B. Documenting the client's blood pressure, heart rate, and
symptoms
C. Determining that the medication caused orthostatic
hypotension
D. Teaching the client to change positions slowly
Correct Answer: B
Rationale: Recognizing cues involves collecting relevant
assessment data. Obtaining and documenting vital signs and
symptoms is part of the assessment process before conclusions
or interventions are made.
,Question 2
Difficulty: Moderate
Question Type: MCQ
Question:
A client receiving opioid analgesics becomes difficult to arouse
and has a respiratory rate of 8 breaths/min. Which action best
reflects the Analyze Cues step?
A. Administer naloxone as prescribed
B. Notify the provider immediately
C. Determine that the findings suggest opioid-induced
respiratory depression
D. Reassess respiratory status in 30 minutes
Correct Answer: C
Rationale: Analyzing cues involves interpreting assessment
findings and identifying their significance. Recognizing that the
symptoms indicate opioid-induced respiratory depression is
analysis rather than intervention.
Question 3
Difficulty: Moderate
, Question Type: SATA
Question:
A nurse is assessing a client before administering digoxin. Which
findings are cues that should be recognized before medication
administration?
Select all that apply.
A. Apical pulse of 54 beats/min
B. Potassium level of 3.0 mEq/L
C. Blood pressure of 128/76 mm Hg
D. Complaint of nausea
E. Reports seeing yellow halos around lights
Correct Answer: A, B, D, E
Rationale: Bradycardia, hypokalemia, nausea, and visual
disturbances may indicate increased risk for digoxin toxicity.
These findings require further evaluation before administration.
Question 4
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question: