ANALYZE CUES

The nurse clustered the following patient cues during the assessment: Sharp pain in lower right abdomen, patient pain rating 9 on a 0-to-10 pain scale, and facial grimacing. Which hypothesis based on International Classification for Nursing Practice (ICNP) terminology can the nurse select when clustering the data? Acute Pain Constipation Abdominal Pain Risk for Vomiting NOT SURE

Abdominal Pain The clustered patient cues (sharp pain in lower right abdomen, pain rated "9", and facial grimacing) support a hypothesis of Abdominal Pain. WRONG: Acute Pain Not enough information is available to determine whether the pain is acute or chronic. The nurse needs to gather additional information before selecting the hypothesis of Acute Pain. Constipation Cues regarding bowel habits are not available. The nurse needs to collect additional patient cues to support a hypothesis of Constipation. Risk for Vomiting Data regarding nausea or other potential cues that would suggest a hypothesis of Risk for Vomiting are not clearly provided. The nurse needs to collect additional patient cues.

Which concepts does the nurse apply when clustering patient data? Select all that apply. Anticipated findings Potential disease processes Prior patient care experiences Stages of growth and development Process for prioritization of hypotheses

Anticipated findings The nurse clusters patient data according to anticipated physical assessment findings when analyzing patient cues. Potential disease processes The nurse organizes patient data according to potential disease processes when analyzing patient cues. Prior patient care experiences Knowledge from prior patient care experiences with similar patients influences the way the nurse clusters patient data. Stages of growth and development An understanding of life span growth and development stages helps the nurse to identify relevant findings when clustering patient data. WRONG: Process for prioritization of hypotheses Prioritization of hypotheses occurs after patient data is clustered and hypotheses are formed.

When analyzing patient cues during the second step of the Clinical Judgment Measurement Model, which strategy provides meaning to cues and insight into the patient's unique circumstances? Developing a nursing diagnosis Clustering similar data into groups Conducting a complete head-to-toe assessment Asking questions to identify patterns among collected cues

Asking questions to identify patterns among collected cues The nurse can ask questions to gain insight into the patient's unique experience and condition, allowing the nurse to identify patterns and derive meaning from the collected cues. WRONG: Developing a nursing diagnosis A nursing diagnosis is an example of a hypothesis the nurse might develop following an analysis of cues. It is not a strategy that provides insight into the patient's unique circumstances during organization of patient data. Clustering similar data into groups Clustering similar data into groups is an essential step of organizing and analyzing patient data; however, it does not provide insight into the patient's unique situation. Conducting a complete head-to-toe assessment The nurse conducts an assessment during the first step of the Clinical Judgment Measurement Model.

Which action is essential for the nurse to complete during step two of applying the Clinical Judgment Measurement Model to nursing practice? Recognize patient cues. Consider environmental factors. Cluster subjective and objective data. Generate solutions based on patient needs.

Cluster subjective and objective data. The nurse clusters subjective and objective patient cues to relate findings to possible disease processes or patient conditions. WRONG: Recognize patient cues. Recognizing patient cues occurs in step one of the Clinical Judgment Measurement Model. Consider environmental factors. Environmental factors are not a component of the "Analyze Cues" step of the Clinical Judgment Measurement Model. This step focuses on interpreting patient cues to cluster data. Generate solutions based on patient needs. The generation of solutions occurs after the analysis of cues, formation of hypotheses, and prioritization of the hypotheses. It is not a component of the second step of the Clinical Judgment Measurement Model.

Which outcome results from analysis of patient assessment data during the second step of the Clinical Judgment Measurement Model? A prioritized list of patient needs A single nursing diagnostic statement Nursing interventions to achieve patient goals Grouping of patient cues according to similarities

Grouping of patient cues according to similarities The nurse clusters objective and subjective patient cues by grouping related or similar data during the second step of the Clinical Judgment Measurement Model. WRONG: A prioritized list of patient needs Prioritization is not an outcome related to the second step of the Clinical Judgment Measurement Model. The focus is on the analysis of patient cues by clustering related or similar data. A single nursing diagnostic statement Analysis of patient assessment data may yield several clusters of related data or cues. It is common to apply several nursing diagnostic statements to one patient. Nursing interventions to achieve patient goals The second step of the Clinical Judgment Measurement Model focuses on the analysis of patient cues, not nursing interventions or goal achievement.

Which statement describes why nurses identify supporting data for a hypothesis? Supporting data validates the patient's plan of care. Identification of supporting data allows the nurse to individualize the plan of care. Documentation of supporting data allows the nurse to prioritize hypotheses. Supporting data provides consistency when planning care for patients experiencing similar conditions.

Identification of supporting data allows the nurse to individualize the plan of care. Nurses use clinical judgment to identify supporting data and develop an appropriate plan of care with individualized patient goals. The same hypotheses with different supporting data can require a different plan of care. WRONG: Supporting data validates the patient's plan of care. The supporting data allows the nurse to individualize the plan of care. It does not validate the plan of care, because the plan of care has not yet been developed at this point. Documentation of supporting data allows the nurse to prioritize hypotheses. Although supporting data can help the nurse to prioritize hypotheses, the reason nurses identify supporting data is to individualize the plan of care for each patient. Supporting data provides consistency when planning care for patients experiencing similar conditions. Supporting data validates the hypothesis and allows individualization of the plan of care.

Place in order the actions the nurse takes when applying the Clinical Judgment Measurement Model to nursing practice. Cluster cues Form hypotheses Recognize cues Link cues

Recognize cues Cluster cues Link cues Form hypotheses When applying the Clinical Judgment Measurement Model, the nurse would perform the actions in the following order: recognize cues, cluster cues, link cues, form hypotheses.

Which functions does the nurse complete during the second step of the Clinical Judgment Measurement Model? Select all that apply. Relate findings to potential disease processes. Examine subjective and objective patient cues. Interpret cues collected during the evaluation phase. Correlate patient cues to conditions by clustering data. Link cues from step one (Assessment) to step two (Recognize Cues).

Relate findings to potential disease processes. The nurse begins to relate findings to possible disease processes by clustering data during the second step of the Clinical Judgment Measurement Model. Examine subjective and objective patient cues. The nurse interprets subjective and objective cues collected in the patient assessment during the second step of the Clinical Judgment Measurement Model. Correlate patient cues to conditions by clustering data. The nurse begins to correlate findings to possible patient conditions by clustering data during the second step of the Clinical Judgment Measurement Model. WRONG: Link cues from step one (Assessment) to step two (Recognize Cues). The Clinical Judgment Measurement Model involves recognizing patient cues (step one), then analyzing the cues to form hypotheses (step two). Interpret cues collected during the evaluation phase. During the second step of the Clinical Judgment Measurement Model (Analyze Cues), the nurse interprets subjective and objective cues collected during the patient assessment, not the evaluation phase.

Which types of factors influence the development of a hypothesis? Select all that apply. Risk Social Indirect Cultural Supportive

Risk The nurse considers risk factors when developing a hypothesis to determine problems a patient might be at risk for developing. Social Social factors promote individualization during the development of hypotheses. Cultural Cultural factors influence the development of hypotheses and allow the nurse to individualize the plan of care. WRONG: Indirect Indirect factors are not a component of developing a hypothesis. Supportive The nurse includes supporting evidence when developing hypotheses; however, supportive factors are not a component of hypothesis development.

Which statement describes how nurses apply the International Classification for Nursing Practice (ICNP) terminology to the second step of the Clinical Judgment Measurement Model? Collect patient cues. Determine outcomes. Prioritize hypotheses. Select nursing diagnoses.

Select nursing diagnoses. Hypotheses can be ICNP nursing diagnoses, and the nurse forms these hypotheses during the second step of the Clinical Judgment Measurement Model. WRONG: Collect patient cues. Patient cues are collected during the assessment as a component of the first step of the Clinical Judgment Measurement Model. ICNP does not play a role in this. Determine outcomes. The ICNP includes thousands of terms and definitions, from which the catalogs, or subsets, of nursing diagnosis, outcome, and intervention statements were developed. The nurse determines outcomes in a later step of the Clinical Judgment Measurement Model, however. Prioritize hypotheses. Hypotheses can be ICNP nursing diagnoses, but hypotheses are prioritized in the third step of the Clinical Judgment Measurement Model after the nurse analyzes and organizes cues.

Which questions help the nurse to cluster and analyze patient data during the second step of the Clinical Judgment Measurement Model? Select all that apply. Which patient findings fit together? Which conditions present with cues like the patient's cues? What other information can help evaluate patient outcomes? Are there any findings or patient cues that seem contradictory? Which patient conditions are expected based on the medical diagnosis?

Which patient findings fit together? Questioning which patient findings fit together will help the nurse group the collected data. Which conditions present with cues like the patient's cues? Asking about conditions with similar cues assists the nurse when clustering data. Are there any findings or patient cues that seem contradictory? Questions about inconsistent patient data assist the nurse when analyzing patient data. Which patient conditions are expected based on the medical diagnosis? A question about expected conditions will help the nurse analyze data collected based on anticipated patient findings. WRONG: What other information can help evaluate patient outcomes? This question is not appropriate for the second step of the Clinical Judgment Measurement Model because it focuses on evaluating patient outcomes instead of clustering and analyzing patient data.

Which labels describe a hypothesis? Select all that apply. Patient problem Objective patient cue Subjective patient cue Diagnosed medical condition Ailment the patient is at risk for developing NOT SURE

atient problem Hypotheses can be patient problems the nurse needs to include in the plan of care to improve the patient's situation, minimize complications, and make the patient feel better. Diagnosed medical condition Hypotheses can include medical conditions the nurse needs to address in the patient plan of care to improve the situation, minimize complications, and make the patient feel better. Ailment the patient is at risk for developing Hypotheses can be actual problems that the patient is currently experiencing, or potential problems, which are those the patient is at risk for developing because of the presence of risk factors for a particular condition. WRONG: Objective patient cue Objective patient cues are observable and measurable data collected during the patient assessment. Subjective patient cue Subjective patient cues are data reported by the patient during the assessment