The nurse provided oral glucose to a client with diabetes. Which step of the clinical judgement measurement model (CJMM) did the nurse utilize?
Recognize cues
Generate solutions
Take action
Evaluate outcomes
The Correct Answer is C
A. Recognize cues: This step involves identifying and interpreting relevant clinical data, such as signs of hypoglycemia (e.g., sweating, shakiness, pallor). While necessary for decision-making, recognizing cues alone does not include the actual intervention.
B. Generate solutions: In this step, the nurse considers possible interventions or strategies to address the identified problem. It is a planning phase and does not involve carrying out the intervention yet.
C. Take action: Administering oral glucose is the execution of the planned intervention to treat hypoglycemia. This step reflects implementing the clinical decision based on the identified cues and chosen solution, directly affecting the client’s immediate status.
D. Evaluate outcomes: This step occurs after the intervention, when the nurse assesses the effectiveness of the action, such as improved blood glucose levels and resolution of hypoglycemic symptoms. It does not include the initial administration of treatment.
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Related Questions
Correct Answer is C
Explanation
A. Colchicine: Colchicine is an anti-inflammatory medication primarily used to treat gout and familial Mediterranean fever. It is not an opioid and does not act on opioid receptors to produce analgesia or sedation.
B. Ibuprofen: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that reduces pain, fever, and inflammation by inhibiting cyclooxygenase enzymes. It does not bind to opioid receptors and is not classified as an opioid.
C. Fentanyl: Fentanyl is a potent synthetic opioid that binds to mu-opioid receptors in the central nervous system, producing analgesia, sedation, and euphoria. It is commonly used for severe pain management and as an adjunct in anesthesia.
D. Acetylsalicylic Acid: Acetylsalicylic acid (aspirin) is an NSAID with analgesic, anti-inflammatory, and antiplatelet properties. It is not an opioid and does not produce the central nervous system effects characteristic of opioids.
Correct Answer is C
Explanation
A. "This drug should make me feel full.": Pioglitazone is a thiazolidinedione used to improve insulin sensitivity in type 2 diabetes. It does not act as an appetite suppressant, so expecting a feeling of fullness reflects a misunderstanding of its mechanism.
B. "This drug may cause flatulence.": While some medications for diabetes, such as alpha-glucosidase inhibitors, can cause flatulence, pioglitazone does not commonly produce this side effect. Expecting gas is not accurate for this drug.
C. "This drug can damage my liver.": Pioglitazone carries a risk of hepatotoxicity, so clients should be aware of signs of liver injury (e.g., jaundice, dark urine, fatigue). This statement demonstrates understanding of a key safety concern associated with the medication.
D. "This drug may cause weight loss.": Pioglitazone is more commonly associated with weight gain due to fluid retention rather than weight loss. Believing it promotes weight loss indicates a misconception about the drug’s effects.
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