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Clinical Judgment and Systems
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Clinical Judgment and SystemsClinical
ThinkingJudgment
Study Guide
and Systems
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Clinical
Thinking
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Judgment
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Systems
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Thinking
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,Clinical Judgement and Systems Thinking.pdf Clinical Judgement and Systems Thinking.pdf Clinical Judgement and Systems Thinking.pdf
Terms in this set (20)
Which action would the nurse include in the plan of care All answers are correct
for a patient at an increased risk for falls because of
confusion? Rationale: Critical thinking involves planning and intervening for patient safety.
- Arrange for a sitter service Therefore all of the nursing interventions planned here would meet those safety
- Obtain a low-profile bed goals. The nurse should arrange for a one to one sitter in the room to make sure
- Make frequent rounds the patient does not attempt to get out of bed or chair without assistance. The
- Reorient the patient to surroundings nurse should also obtain a low-profile bed so if the patient does get out of bed, it
- Place the patient near the nurse's station is only 6 inches off the floor. The nurse should also work with assistive personnel
to make frequent rounds to check on the patient. The nurse should help reorient
the patient to the surroundings. Another safety intervention would include
assigning the patient to a room near the nurses' station. This allows for frequent
visualization of the patient.
Clinical Judgement and Systems Thinking.pdf Clinical Judgement and Systems Thinking.pdf Clinical Judgement and Systems Thinking.pdf
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The nurse is using the Clinical Judgement Model to plan Analyze Cues
care for a patient admitted after experiencing a heart
attack. Which step would the nurse perform based on Rationale: The nurse has recognized the cues above in the subjective and
the findings below? (view Photo) objective data. Therefore, the next step would be to analyze cues. The nurse
- Take action should take action after prioritizing hypotheses and generating solutions. (Pg20)
- Analyze clues
- Generate solutions
- Prioritize hypotheses
The nurse is reviewing the medical record of a patient Measure the wound
seen in the home care setting. Based on the documented
information, which action would the nurse perform in the Rationale: The planning stage would occur after assessment data are obtained.
planning stage of assessing, analyzing, planning, The nursing documentation states the wound appears larger. Therefore the nurse
implementing, and evaluating (AAPIE) process? (View should plan to measure the wound. This would provide more information to
photo) determine whether to revise the plan of care. Implementation would be to turn
- Measure wound the patient every 2 hours to relieve pressure and perform wound care.
- Turn patient every 2 hours Assessment would occur when the nurse assesses for pressure points (pg19)
- Perform wound care
- Assess pressure points
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Clinical Judgement and Systems Thinking.pdf Clinical Judgement and Systems Thinking.pdf Clinical Judgement and Systems Thinking.pdf