A nurse is discussing the revision of care plans with a newly licensed nurse. During which of the following steps of the Clinical Judgment Action Model (CJAM) should revisions take place?

A. This step involves interpreting the data collected from the client to identify patterns or potential problems. It helps form clinical judgments but does not involve revising the care plan.

B. This is the first step of the Clinical Judgment Action Model (CJAM) and involves noticing relevant data from assessments and reports. It is about identifying what information is important, not about making revisions.

C. Revisions to the care plan occur during this step. After interventions are implemented, the nurse evaluates the client’s response and determines whether the outcomes were achieved. If goals are unmet or only partially met, the nurse revises the care plan to improve effectiveness.

D. This step involves developing possible interventions or actions based on the analysis of cues. It focuses on planning care rather than modifying or revising existing care plans.

A. This scenario demonstrates false imprisonment, not negligence. The nurse is unlawfully restricting the client’s freedom of movement despite the client being competent and making an informed decision.

B. This represents assault, not negligence. The nurse is making a threat to physically restrain the client, which can cause fear or anxiety, fulfilling the definition of assault.

C. This is negligence because the nurse failed to take timely action when a critical finding was identified. The absence of a peripheral pulse in a casted limb indicates compromised circulation and possible compartment syndrome, a medical emergency that requires immediate intervention. Delaying notification to the provider places the client at risk for permanent tissue damage or loss of limb, meeting the definition of negligence — failure to act as a reasonably prudent nurse would under similar circumstances.

D. This describes battery, not negligence. Battery occurs when a nurse intentionally touches or treats a client without consent, even if the intent is beneficial. It violates the client’s right to autonomy and informed consent.