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 receiving a newly
prescribed antihypertensive medication. The client reports
dizziness when standing. Which action best reflects the
Recognize Cues (Assessment) step of the CJMM?
• A. Hold the medication and notify the provider
• B. Reassess blood pressure in lying and standing positions
• C. Educate the client about orthostatic precautions
• D. Document that the medication was administered
Correct Answer: B
Rationale: Recognizing cues involves collecting relevant
assessment data. Measuring orthostatic blood pressures
gathers information needed to determine whether the dizziness
is related to hypotension.
Question 2
Difficulty: Moderate
Question Type: Select All That Apply
,Question: A nurse is assessing a client who received IV
morphine 30 minutes ago. Which findings are cues that require
further analysis?
• Respiratory rate 8/min
• Oxygen saturation 89%
• Reports pain 2/10
• Difficult to arouse
• Blood pressure 88/50 mm Hg
Correct Answer: A, B, D, E
Rationale: These findings suggest possible opioid-induced
respiratory depression and hypotension. A pain score of 2/10
indicates therapeutic pain relief and is not the priority cue
requiring further analysis.
Question 3
Difficulty: Moderate
Question Type: Multiple Choice
Question: A client taking warfarin has an INR of 5.8 and reports
bleeding gums. Which step of the CJMM is the nurse using
when determining that the client is at high risk for hemorrhage?
• A. Recognize cues
• B. Analyze cues
, • C. Generate solutions
• D. Evaluate outcomes
Correct Answer: B
Rationale: Analyze cues means interpreting assessment findings
and connecting them to a clinical problem. The elevated INR
and bleeding gums indicate increased anticoagulation and
hemorrhage risk.
Question 4
Difficulty: Difficult
Question Type: NGN Clinical Judgment
Case Scenario
NGN
Client Data
Post-op
A postoperative client is receiving IV gentamicin.
Finding Value
Urine output 20 mL/hr
Creatinine 2.1 mg/dL
Hearing Reports ringing in the ears
Question