ch 7 Prioritize Hypotheses

Question 1

Which action comprises the third step of the Clinical Judgment Measurement Model?
- Analyze cues
- Recognize cues
- Form hypotheses
- Prioritize hypotheses

Answer 1

Prioritize hypotheses

Question 2

Which questions would the nurse consider when prioritizing hypotheses?
- Which patient cues fit together?
- What are the risks for other hypotheses?
- Which findings are expected based on the patient’s condition?
- Which hypothesis is most important and should be managed first?
- What other information can help determine the significance of the cues?

Answer 2

• What are the risks for other hypotheses?
• Which hypothesis is most important and should be managed first?

Question 3

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
- Temperature of 104°F (40°C)
- Heart rate of 140 BPM
- Oxygen saturation (SpO2) of 85%
- Blood pressure reading of 138/88 mm Hg

Answer 3

• Severe chest pain
• Temperature of 104°F (40°C)
• Heart rate of 140 BPM
• Oxygen saturation (SpO2) of 85%

Question 4

Which priority patient cues would the nurse promptly report to the health care provider when analyzing findings from a patient assessment?
- Critical laboratory values
- Severe chest pain
- Respiratory distress
- Patient report of discomfort
- Extremely elevated temperature

Answer 4

• Critical laboratory values
• Severe chest pain
• Respiratory distress
• Extremely elevated temperature

Question 5

Place the nursing actions associated with applying the Clinical Judgment Measurement Model to nursing practice in the order they should occur.
- Form hypotheses.
- Cluster cues.
- Recognize cues.
- Rank hypotheses.
- Ealuate hypotheses.

Answer 5

• Recognize cues.
• Cluster cues.
• Form hypotheses.
• Evaluate hypotheses.
• Rank hypotheses.

Question 6

Based on urgency and risk, which hypothesis would the nurse rank as the priority?
- Risk for Activity Intolerance; supporting data: increased fatigue, difficulty breathing, dyspnea
- Self-Care Deficit; supporting data: inability to ambulate autonomously, inability to bathe independently
- Hypervolemia; supporting data: coarse crackles, dyspnea, 2+ edema, hypertension, heart failure diagnosis
- Urinary Tract Infection; supporting data: persistent urge to urinate, foul-smelling urine, burning sensation when urinating, low-grade fever

Answer 6

Hypervolemia; supporting data: coarse crackles, dyspnea, 2+ edema, hypertension, heart failure diagnosis

Question 7

Match the priority concept the nurse uses to evaluate and rank hypotheses with the corresponding hypotheses and supporting data.
Likelihood:
- Hypertension, supporting data: BP 150/90
- Inactivity, supporting data: fractured left ankle, pain upon movement
- Acute respiratory distress, supporting data: SaO2 89%, dyspnea

Answer 7

Inactivity, supporting data: fractured left ankle, pain upon movement

Question 8

Match the priority concept the nurse uses to evaluate and rank hypotheses with the corresponding hypotheses and supporting data.
Risk:
- Hypertension, supporting data: BP 150/90
- Inactivity, supporting data: fractured left ankle, pain upon movement
- Acute respiratory distress, supporting data: SaO2 89%, dyspnea

Answer 8

Hypertension, supporting data: BP 150/90

Question 9

Match the priority concept the nurse uses to evaluate and rank hypotheses with the corresponding hypotheses and supporting data.
Urgency:
- Hypertension, supporting data: BP 150/90
- Inactivity, supporting data: fractured left ankle, pain upon movement
- Acute respiratory distress, supporting data: SaO2 89%, dyspnea

Answer 9

Acute respiratory distress, supporting data: SaO2 89%, dyspnea