Clinical Judgement Sherpath Questions & Answers Already Graded A+
To effectively recognize patient cues, which concepts would the nurse need to understand?
The first few minutes of the patient encounter are critical.
(It is easy to focus on tasks that need to be done when the nurse enters the ...
Clinical Judgement Sherpath Questions & Answers
Already Graded A+
To effectively recognize patient cues, which concepts would the nurse need to
understand?
The first few minutes of the patient encounter are critical.
(It is easy to focus on tasks that need to be done when the nurse enters the patient's
room. However, if the nurse leaps into task completion without taking time to listen to
the patient and observe the patient's environment and nonverbal communication, the
nurse can overlook key information and miss patient cues.)
A nonjudgmental environment promotes communication.
(The nurse needs to ensure a nonjudgmental environment to promote effective
communication of subjective patient cues.)
The nurse should adapt the physical assessment based on patient age.
(Developmental level and age can influence a patient's ability to communicate cues
during a patient interview.)
Which factors can hinder the nurse's ability to recognize patient cues?
The patient is 3 years old.
(A patient's age and developmental level can create a barrier to effective
communication)
The patient is crying uncontrollably.
(Stress, as evidenced by uncontrollable crying, can create feelings of frustration and
anxiety, which can negatively affect communication.)
The patient does not speak English as a first language.
(Language can create a barrier when the nurse and patient do not understand each
other. Translators should be used to promote effective communication.)
The patient's culture discourages eye contact with strangers.
(An individual's cultural background can influence the way someone communicates and
the interpretation of verbal and nonverbal cues.)
Which examples are objective patient cues collected from the electronic health
record?
Potassium level is 3.5 mmol/L.
(The electronic health record includes a complete report of overall health, including
laboratory test values.)
Blood pressure is 118/70 mm Hg.
(The electronic health record includes a comprehensive report of overall health,
including vital signs.)
Heart rate is 72 beats/min.
,(The electronic health record includes a thorough report of overall health, including vital
signs.)
Bowel sounds are heard in all quadrants.
(The electronic health record includes a thorough report of overall health, including
findings from the physical examination.)
Which factor can influence the nurse's ability to recognize and categorize patient
cues?
Experience with other patients
(The nurse's experience with other patients can influence recognition and categorization
of cues based on the progression of care for prior patients.)
Which patient cue would the nurse categorize as "important" for a patient
diagnosed with a femur fracture?
Temperature of 102.4°F (39°C)
(Urgent patient cues demand immediate attention and generally relate to airway,
breathing, circulation, or safety. An elevated temperature can be categorized as
important since it is the most significant finding presented and indicates the potential of
infection, but it will not necessarily influence airway, breathing, circulation, or safety.)
The answer to which question would help the nurse categorize patient cues
according to the degree of concern?
Which cues demand immediate attention?
(Data are categorized based on degree of concern or urgency if they demand
immediate attention.)
Which patient cue would the nurse categorize as "urgent" for a patient diagnosed
with pneumonia?
Shortness of breath
(Urgent patient cues demand immediate attention and generally relate to airway,
breathing, circulation, or safety.)
During the first three steps of the Clinical Judgment Measurement Model, the
nurse ...
Completes a health history, clusters patient data, and prioritizes hypotheses.
Which questions would the nurse consider when prioritizing hypotheses?
What are the risks for other hypotheses?
(Determining risks for rank ordering hypotheses supports the prioritization of
hypotheses.)
Which hypothesis is most important and should be managed first?
(Consideration of which hypothesis is most important and should be managed first
allows the nurse to prioritize hypotheses.)
Which patient cues would the nurse identify as priority and promptly report to the
health care provider when analyzing findings from the assessment of a 30-year-
old patient?
Severe chest pain
(Severe chest pain, which could indicate an urgent medical issue, should be quickly
reported to the health care provider.)
, Temperature of 104°F (40°C)
(Extremely high vital signs, such as elevated temperature of 104°F (40°C), should be
swiftly reported to the health care provider.)
Heart rate of 140 BPM
(Critically elevated vital signs, such as tachycardia, should be rapidly reported to the
health care provider.)
Oxygen saturation (SpO2) of 85%
(Exceptionally low vital signs, such as a low oxygen saturation of 85%, should be
quickly reported to the health care provider.)
Which priority patient cues would the nurse promptly report to the health care
provider when analyzing findings from a patient assessment?
Critical laboratory values
(Critical laboratory values (those that can impact the pathophysiologic state and
become life-threatening) should be rapidly reported to the health care provider.)
Severe chest pain
(Severe chest pain, which could indicate an urgent medical issue, should be quickly
reported to the health care provider.)
Respiratory distress
(Respiratory distress, potentially indicating an urgent condition, should be quickly
reported to the health care provider.)
Extremely elevated temperature
(Critically elevated vital signs, such as an extremely elevated temperature, should be
rapidly reported to the health care provider.)
Place the nursing actions associated with applying the Clinical Judgment
Measurement Model to nursing practice in the order they should occur.
These nursing actions associated with the Clinical Judgment Measurement Model
should occur in the following order: recognize cues, cluster cues, form hypotheses,
evaluate hypotheses, rank hypotheses.
Which action comprises the third step of the Clinical Judgment Measurement
Model?
Prioritize hypotheses
(Prioritizing hypotheses occurs during step three of the Clinical Judgment Measurement
Model)
Match the priority concept the nurse uses to evaluate and rank hypotheses with
the corresponding hypotheses and supporting data.
Hypertension, supporting data: BP 150/90 - Risk
Inactivity, supporting data: fractured left ankle, pain upon movement - Likelihood
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