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 preparing to administer a newly prescribed
medication. Before giving the medication, the nurse reviews the
patient's allergies, current vital signs, and recent laboratory
results. Which step of the Clinical Judgment Measurement
Model (CJMM) is the nurse performing?
A. Take Action
B. Recognize Cues
C. Generate Solutions
D. Evaluate Outcomes
Correct Answer: B. Recognize Cues
Rationale: Recognize Cues involves collecting relevant patient
information through assessment, including allergies, vital signs,
laboratory values, and medication history before making clinical
decisions.
Question 2
Difficulty: Moderate
Question Type: Multiple Choice (MCQ)
,Question:
A patient receiving an opioid reports increasing drowsiness, and
the respiratory rate decreases from 18 to 10 breaths/min.
Which CJMM step requires the nurse to determine the
significance of these findings?
A. Recognize Cues
B. Analyze Cues
C. Take Action
D. Evaluate Outcomes
Correct Answer: B. Analyze Cues
Rationale: Analyze Cues requires interpreting assessment
findings to determine their clinical significance. The nurse
recognizes that opioid-induced respiratory depression is
developing.
Question 3
Difficulty: Moderate
Question Type: Select All That Apply (SATA)
Question:
A nurse is caring for a patient receiving intravenous antibiotics.
Which assessment findings should the nurse recognize as cues
requiring further evaluation?
, A. New generalized rash
B. Temperature of 38.9°C (102°F)
C. Stable blood pressure within baseline
D. Complaints of difficulty breathing
E. Swelling of the lips
Correct Answer: A, B, D, E
Rationale: Rash, fever, breathing difficulty, and lip swelling may
indicate infection progression or an allergic reaction requiring
prompt assessment. A stable blood pressure alone is not an
abnormal cue.
Question 4
Difficulty: Moderate
Question Type: NGN Clinical Judgment
Question:
A patient receives the first dose of an antihypertensive
medication. Thirty minutes later the patient reports dizziness
while standing.
What is the nurse's priority hypothesis?
A. The patient is experiencing expected orthostatic
hypotension.
B. The medication has no therapeutic effect.