Comprehensive Clinical
Reasoning Assessment:
Aligning with NCSBN CJMM &
Harding's Clinical Reasoning
Cases in Nursing, 8th Ed.
Recognizing & Analyzing Cues (Assessment & Data Interpretation)
Q1: Which of the following definitions best describes the "Recognizing Cues" step of the
Clinical Judgment Measurement Model (CJMM)?
A. Developing a plan of care based on patient goals and expected outcomes.
B. Identifying relevant clinical data from the patient, family, and electronic health record.
C. Organizing and analyzing the identified cues to identify patterns.
D. Evaluating the effectiveness of nursing interventions after implementation.
[CORRECT]
Correct Answer: B
Rationale: The best answer is B because Recognizing Cues is the first cognitive step in
the CJMM where the nurse collects subjective and objective data, essentially "gathering
the dots" before connecting them.
Q2: A nurse is assessing a client who is 12 hours post-op following a total hip
replacement. The client reports pain as a 7 on a scale of 0 to 10, but the nurse notices
the client is restless, grimacing, and refusing to move. Which cue is the most significant
indicator of the client's pain status?
A. The client's verbal report of pain as a 7.
B. The client's refusal to move.
C. The client's restlessness and facial grimacing.
D. The time elapsed since the surgery. [CORRECT]
Correct Answer: C
Rationale: Behavioral cues like restlessness and grimacing are often more reliable
indicators of severe pain than a self-reported number, especially when the nonverbal
cues contradict the stated intensity or suggest the client is minimizing their distress.
,Q3: When "Analyzing Cues," the nurse identifies that a client with a history of heart
failure has gained 3 kg in two days, has jugular vein distension (JVD), and has bilateral
crackles in the lung bases. What is the nurse identifying in this step?
A. Potential complications
B. Normal physiological variations
C. Irrelevant data
D. The client's primary social support system [CORRECT]
Correct Answer: A
Rationale: This choice is correct because the nurse is clustering signs of fluid overload
(weight gain, JVD, crackles) to recognize that the client is experiencing a complication
of their condition, likely acute decompensated heart failure.
Q4: A client presents with sudden onset of sharp chest pain that worsens on inspiration.
The nurse notes a heart rate of 112 bpm and a respiratory rate of 24 bpm. Which piece
of data is considered a "subtle cue" that might be missed if the nurse focuses only on
the pain?
A. The sharp nature of the chest pain.
B. The increased respiratory rate.
C. The presence of a friction rub on auscultation.
D. The client's report of anxiety. [CORRECT]
Correct Answer: C
Rationale: A pericardial friction rub is a specific, subtle auscultation finding that points
toward pericarditis rather than a more common myocardial infarction, requiring careful
listening to identify.
Q5: The nurse reviews the following laboratory results for a client receiving
chemotherapy: White blood cells (WBC) 2,000/mm³, Hemoglobin 12 g/dL, Platelets
40,000/mm³. Which result is the priority for immediate intervention to prevent
life-threatening complications?
A. WBC of 2,000/mm³
B. Hemoglobin of 12 g/dL
C. Platelets of 40,000/mm³
D. All are equally critical. [CORRECT]
Correct Answer: A
Rationale: While all values are abnormal, the neutropenia (low WBC) places the client
at the highest immediate risk for life-threatening sepsis, requiring strict protective
isolation and monitoring for infection.
, Q6: The nurse is caring for a client with a cast on the right leg. Which assessment
finding should the nurse recognize as an early sign of compartment syndrome?
A. Capillary refill of 3 seconds.
B. Pain that is unrelieved by medication and is disproportionate to the injury.
C. Complaints of itching under the cast.
D. Slight edema of the toes. [CORRECT]
Correct Answer: B
Rationale: This choice is correct because the "5 Ps" of compartment syndrome include
pain that is out of proportion to the injury and unrelieved by opioids, which is a critical
early warning sign of increasing compartment pressure.
Q7: A nurse is reviewing the telemetry monitor of a client and notes a regular rhythm
with a rate of 52 bpm, a PR interval of 0.20 seconds, and a QRS complex of 0.08
seconds. The P wave is upright and consistent. How should the nurse analyze these
cues?
A. Sinus bradycardia
B. First-degree heart block
C. Normal sinus rhythm
D. Second-degree heart block type I [CORRECT]
Correct Answer: A
Rationale: The rhythm is regular, the P waves are normal, and all intervals are within
normal limits except the rate, which is less than 60 bpm, fitting the definition of sinus
bradycardia.
Q8: A client with diabetes mellitus is confused and diaphoretic. The nurse checks the
blood glucose and it is 52 mg/dL. The nurse also notes the client has a history of
hypertension. Which cues are relevant to the immediate clinical situation?
A. History of hypertension and confusion.
B. Blood glucose of 52 mg/dL, confusion, and diaphoresis.
C. Diaphoresis and history of diabetes.
D. Confusion and age of the client. [CORRECT]
Correct Answer: B
Rationale: This choice is correct because the hypoglycemia (52 mg/dL) is directly
causing the confusion and diaphoresis, representing a cluster of cues that defines an
acute emergency (neuroglycopenic symptoms).
Q9: When admitting a client with depression, the nurse asks, "Do you have any
thoughts of harming yourself?" This is an example of which type of cue?
A. Objective data
Reasoning Assessment:
Aligning with NCSBN CJMM &
Harding's Clinical Reasoning
Cases in Nursing, 8th Ed.
Recognizing & Analyzing Cues (Assessment & Data Interpretation)
Q1: Which of the following definitions best describes the "Recognizing Cues" step of the
Clinical Judgment Measurement Model (CJMM)?
A. Developing a plan of care based on patient goals and expected outcomes.
B. Identifying relevant clinical data from the patient, family, and electronic health record.
C. Organizing and analyzing the identified cues to identify patterns.
D. Evaluating the effectiveness of nursing interventions after implementation.
[CORRECT]
Correct Answer: B
Rationale: The best answer is B because Recognizing Cues is the first cognitive step in
the CJMM where the nurse collects subjective and objective data, essentially "gathering
the dots" before connecting them.
Q2: A nurse is assessing a client who is 12 hours post-op following a total hip
replacement. The client reports pain as a 7 on a scale of 0 to 10, but the nurse notices
the client is restless, grimacing, and refusing to move. Which cue is the most significant
indicator of the client's pain status?
A. The client's verbal report of pain as a 7.
B. The client's refusal to move.
C. The client's restlessness and facial grimacing.
D. The time elapsed since the surgery. [CORRECT]
Correct Answer: C
Rationale: Behavioral cues like restlessness and grimacing are often more reliable
indicators of severe pain than a self-reported number, especially when the nonverbal
cues contradict the stated intensity or suggest the client is minimizing their distress.
,Q3: When "Analyzing Cues," the nurse identifies that a client with a history of heart
failure has gained 3 kg in two days, has jugular vein distension (JVD), and has bilateral
crackles in the lung bases. What is the nurse identifying in this step?
A. Potential complications
B. Normal physiological variations
C. Irrelevant data
D. The client's primary social support system [CORRECT]
Correct Answer: A
Rationale: This choice is correct because the nurse is clustering signs of fluid overload
(weight gain, JVD, crackles) to recognize that the client is experiencing a complication
of their condition, likely acute decompensated heart failure.
Q4: A client presents with sudden onset of sharp chest pain that worsens on inspiration.
The nurse notes a heart rate of 112 bpm and a respiratory rate of 24 bpm. Which piece
of data is considered a "subtle cue" that might be missed if the nurse focuses only on
the pain?
A. The sharp nature of the chest pain.
B. The increased respiratory rate.
C. The presence of a friction rub on auscultation.
D. The client's report of anxiety. [CORRECT]
Correct Answer: C
Rationale: A pericardial friction rub is a specific, subtle auscultation finding that points
toward pericarditis rather than a more common myocardial infarction, requiring careful
listening to identify.
Q5: The nurse reviews the following laboratory results for a client receiving
chemotherapy: White blood cells (WBC) 2,000/mm³, Hemoglobin 12 g/dL, Platelets
40,000/mm³. Which result is the priority for immediate intervention to prevent
life-threatening complications?
A. WBC of 2,000/mm³
B. Hemoglobin of 12 g/dL
C. Platelets of 40,000/mm³
D. All are equally critical. [CORRECT]
Correct Answer: A
Rationale: While all values are abnormal, the neutropenia (low WBC) places the client
at the highest immediate risk for life-threatening sepsis, requiring strict protective
isolation and monitoring for infection.
, Q6: The nurse is caring for a client with a cast on the right leg. Which assessment
finding should the nurse recognize as an early sign of compartment syndrome?
A. Capillary refill of 3 seconds.
B. Pain that is unrelieved by medication and is disproportionate to the injury.
C. Complaints of itching under the cast.
D. Slight edema of the toes. [CORRECT]
Correct Answer: B
Rationale: This choice is correct because the "5 Ps" of compartment syndrome include
pain that is out of proportion to the injury and unrelieved by opioids, which is a critical
early warning sign of increasing compartment pressure.
Q7: A nurse is reviewing the telemetry monitor of a client and notes a regular rhythm
with a rate of 52 bpm, a PR interval of 0.20 seconds, and a QRS complex of 0.08
seconds. The P wave is upright and consistent. How should the nurse analyze these
cues?
A. Sinus bradycardia
B. First-degree heart block
C. Normal sinus rhythm
D. Second-degree heart block type I [CORRECT]
Correct Answer: A
Rationale: The rhythm is regular, the P waves are normal, and all intervals are within
normal limits except the rate, which is less than 60 bpm, fitting the definition of sinus
bradycardia.
Q8: A client with diabetes mellitus is confused and diaphoretic. The nurse checks the
blood glucose and it is 52 mg/dL. The nurse also notes the client has a history of
hypertension. Which cues are relevant to the immediate clinical situation?
A. History of hypertension and confusion.
B. Blood glucose of 52 mg/dL, confusion, and diaphoresis.
C. Diaphoresis and history of diabetes.
D. Confusion and age of the client. [CORRECT]
Correct Answer: B
Rationale: This choice is correct because the hypoglycemia (52 mg/dL) is directly
causing the confusion and diaphoresis, representing a cluster of cues that defines an
acute emergency (neuroglycopenic symptoms).
Q9: When admitting a client with depression, the nurse asks, "Do you have any
thoughts of harming yourself?" This is an example of which type of cue?
A. Objective data
