Developing Clinical Judgment for Professional Nursing and the Next-Generation NCLEX-RN® Examination (2020)

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PART 1. Introduction: Developing Clinical
Judgment
1. Transitioning from the nursing process to clinical judgment
Review of the nursing process and critical thinking
Expanding from the nursing process to clinical judgment
New nursing graduates and clinical judgment
The National Council of State Boards of Nursing Clinical
Judgment Measurement Model
Thinking and discussion questions
References
2. Applying the NCSBN clinical judgment measurement model to
ensure client safety
Overview of the NCSBN CJMM
Applying the cognitive skills of the NCSBN CJMM
Applying the NCSBN CJMM for thinking exercises in this
workbook
Enhanced hot spot thinking exercises
Cloze thinking exercises
Extended drag and drop thinking exercises
Extended multiple response thinking exercises
Matrix thinking exercises

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Thinking and discussion questions
Bibliography
PART 2. Clinical Judgment for Clients Across the
Life Span Experiencing Commonly Occurring
Health Problems
3. Perfusion: Common Health Problems
Exemplar 3A. Heart failure (Medical-surgical nursing: Older
adult)
Exemplar 3B. Sickle cell disease (Pediatric nursing: Adolescent)
4. Cloing: Deep Vein Thrombosis
Exemplar 4. Deep vein thrombosis (Medical-surgical nursing:
Middle-age adult)
5. Gas exchange: Common Health Problems
Exemplar 5A. Asthma (Pediatric nursing: School-age child)
Exemplar 5B. Chronic obstructive pulmonary disease (Medical-
surgical nursing: Middle-age adult)
6. Elimination: Benign Prostatic Hyperplasia
Exemplar 6. Benign prostatic hyperplasia (Medical-surgical
nursing: Older adult)
7. Nutrition: Common Health Problems

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Exemplar 7A. Cholecystitis/cholecystectomy (Medical-surgical
nursing: Middle-age adult)
Exemplar 7B. Peptic ulcer disease (Medical-surgical nursing:
Middle-age adult)
8. Mobility: Common Health Problems
Exemplar 8A. Fractured hip/open reduction internal fixation
(Medical-surgical nursing: Older adult)
Exemplar 8B. Fractured radius and medial epicondyle (Pediatric
nursing: Preschool child)
Exemplar 8C. Osteoarthritis/total knee arthroplasty (Medical-
surgical nursing: Middle-age adult)
Exemplar 8D. Parkinson disease (Medical-surgical
nursing/mental health nursing: Older adult)
9. Metabolism: Common Health Problems
Exemplar 9A. Diabetes mellitus (Medical-surgical nursing:
Middle-age adult)
Exemplar 9B. Hyperthyroidism/thyroidectomy (Medical-surgical
nursing: Middle-age adult)
10. Cellular regulation: Breast Cancer
Exemplar 10. Breast cancer (Medical-surgical nursing: Middle-
age adult)
11. Inflammation: Common Health Problems

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Exemplar 11A. Crohn’s disease (Medical-surgical nursing:
Young adult; middle-age adult)
Exemplar 11B. Appendicitis/appendectomy (Pediatric nursing:
Late school-age child)
12. Infection: Common Health Problems
Exemplar 12A. Cellulitis (Medical-surgical nursing: Middle-age
adult)
Exemplar 12B. Respiratory syncytial virus (RSV) (Pediatric
nursing: Infant)
13. Sensory perception: Cataracts
Exemplar 13. Cataracts (Medical-surgical nursing: Older adult)
14. Cognition: Common Health Problems
Exemplar 14A. Delirium (Mental health nursing: Older adult)
Exemplar 14B. Alzheimer’s disease (Mental health nursing:
Middle-age adult)
15. Mood and affect: Depression
Exemplar 15. Depression (Mental health nursing: Adolescent)
16. Stress and coping: Generalized Anxiety Disorder
Exemplar 16. Generalized anxiety disorder (Mental health
nursing: Young adult)

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17. Reproduction: Uterine Leiomyoma/Hysterectomy
Exemplar 17. Uterine leiomyoma/hysterectomy (Medical-
surgical nursing: Middle-age adult)
PART 3. Clinical Judgment for Childbearing
Families
18. Reproduction: Childbearing Family
Exemplar 18A. Uncomplicated prenatal woman
Exemplar 18B. Complicated prenatal woman
Exemplar 18C. Uncomplicated intrapartum care
Exemplar 18D. Complicated intrapartum care
Exemplar 18E. Uncomplicated postpartum care
Exemplar 18F. Complicated postpartum care
Exemplar 18G. Uncomplicated newborn care
PART 4. Clinical Judgment for Clients Across the
Life Span Experiencing Complex Multisystem
Health Problems
19. Perfusion: Complex Health Problems
Exemplar 19A. Myocardial infarction (Medical-surgical nursing:
Middle-age adult)
Exemplar 19B. Atrial fibrillation/stroke (Medical-surgical nursing:
Older adult)

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Exemplar 19C. Hypovolemic shock (Medical-surgical nursing:
Older adult)
20. Mobility: Spinal Cord Injury
Exemplar 20. Spinal cord injury (Pediatric nursing: Adolescent)
21. Cognition: Traumatic Brain Injury
Exemplar 21. Traumatic brain injury (Medical-surgical nursing:
Older adult and young adult)
22. Infection: Sepsis
Exemplar 22. Sepsis (Medical-surgical nursing: Older adult)
23. Gas exchange: Chest Trauma
Exemplar 23. Chest trauma (Medical-surgical nursing: Middle-
age adult)
24. Elimination: Complex Health Problems
Exemplar 24A. Chronic kidney disease (Medical-surgical
nursing: Middle-age adult)
Exemplar 24B. Intestinal obstruction (Medical-surgical nursing:
Young adult; older adult)
25. Metabolism: Complex Health Problems
Exemplar 25A. Diabetic ketoacidosis (Pediatric nursing:
Adolescent)

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Exemplar 25B. Cirrhosis (Medical-surgical nursing: Older adult)
Exemplar 25C. Acute pancreatitis (Medical-surgical nursing:
Middle-age adult)
26. Tissue integrity: Burns
Exemplar 26. Burns (Medical-surgical nursing: Young adult)
27. Stress and coping: Substance Use Disorder
Exemplar 27. Substance use disorder (Pediatric nursing/mental
health nursing: Adolescent)
28. Management of care: Complex Health Problems
Exemplar 28. Complex health problems (Medical-surgical
nursing: Middle-age and older adult)
PART 5. Pharmacology for Nursing
29. Pharmacology in management of common health problems
Exemplar 29A. Drugs that affect nutrition and elimination
(Medical-surgical nursing: Older adult; pediatric nursing)
Exemplar 29B. Drugs that affect clotting (Medical-surgical
nursing: Middle-age and older adult)
Exemplar 29C. Drugs that affect perfusion (Medical-surgical
nursing: Middle-age and older adult)
Exemplar 29D. Drugs that promote comfort and metabolism
(Medical-surgical nursing: Middle-age and older adult)

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Exemplar 29E. Drugs that manage infection (Medical-surgical
nursing [young and middle-age adult]; pediatric nursing)
30. Pharmacology in management of complex health problems
Exemplar 30A. Drugs that affect perfusion and gas exchange
(Medical-surgical nursing: older adult; pediatric nursing:
Adolescent)
Exemplar 30B. Drugs that affect immunity (Medical-surgical
nursing: Young adult; middle-age adult)
Exemplar 30C. Drugs that manage psychoses (Mental health
nursing: Young adult)
Exemplar 30D. Drugs that manage emergencies (Medical-
surgical nursing: Young adult; older adult)
Answer key
Chapter 3 Perfusion: Common health problems
Chapter 4 Clotting: Deep vein thrombosis
Chapter 5 Gas exchange: Common health problems
Chapter 6 Elimination: Benign prostatic hyperplasia
Chapter 7 Nutrition: Common health problems
Chapter 8 Mobility: Common health problems
Chapter 9 Metabolism: Common health problems
Chapter 10 Cellular regulation: Breast cancer
Chapter 11 Inflammation: Common health problems

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Chapter 12 Infection: Common health problems
Chapter 13 Sensory perception: Cataracts
Chapter 14 Cognition: Common health problems
Chapter 15 Mood and affect: Depression
Chapter 16 Stress and coping: Generalized anxiety disorder
Chapter 17 Reproduction: Uterine leiomyoma/hysterectomy
Chapter 18 Reproduction: Childbearing family
Chapter 19 Perfusion: Complex health problems
Chapter 20 Mobility: Spinal cord injury
Chapter 21 Cognition: Traumatic brain injury
Chapter 22 Infection: Sepsis
Chapter 23 Gas exchange: Chest trauma
Chapter 24 Elimination: Complex health problems
Chapter 25 Metabolism: Complex health problems
Chapter 26 Tissue integrity: Burns
Chapter 27 Stress and coping: Substance use disorder
Chapter 28 Management of care: Complex health problems
Chapter 29 Pharmacology in management of common health
problems
Chapter 30 Pharmacology in management of complex health
problems

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Copyright
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043
DEVELOPING CLINICAL JUDGMENT FOR PROFESSIONAL
NURSING AND THE NEXT-GENERATION NCLEX-RN®
EXAMINATION ISBN: 978-0-323-71858-5
Copyright © 2021 by Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmied in any
form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details on
how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing
Agency, can be found at our website:
www.elsevier.com/permissions.
This book and the individual contributions contained in it are
protected under copyright by the Publisher (other than as may be
noted herein).
Notice
Practitioners and researchers must always rely on their own
experience and knowledge in evaluating and using any

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information, methods, compounds or experiments described
herein. Because of rapid advances in the medical sciences, in
particular, independent verification of diagnoses and drug
dosages should be made. To the fullest extent of the law, no
responsibility is assumed by Elsevier, authors, editors or
contributors for any injury and/or damage to persons or property
as a maer of products liability, negligence or otherwise, or from
any use or operation of any methods, products, instructions, or
ideas contained in the material herein.
International Standard Book Number: 978-0-323-71858-5
Executive Content Strategist: Lee Henderson
Director, Content Development: Laurie Gower
Senior Content Development Specialist: Laura Goodrich
Publishing Services Manager: Julie Eddy
Senior Project Manager: Jodi M. Willard
Design Direction: Amy Buxton
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

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Reviewers
Kiy Cashion, RN-BC, MSN, Clinical Nurse Specialist,
Department of Obstetrics and Gynecology, Division of Maternal-
Fetal Medicine, University of Tennessee Health Science Center,
Memphis, Tennessee
Brigid Chvilicek, MSN, RN, CPNP, Faculty of Nursing,
Wenatchee Valley College, Wenatchee, Washington
Monica Dobbins, RN, Nursing Instructor, Butler Community
College, El Dorado, Kansas
Jessica Hoy, RN, MSNE, PCCN-K, Assistant Professor of
Nursing, College of Saint Scholastica, Duluth, Minnesota
Kay R. Jansen, DNP, RN, Undergraduate Program Director,
University of Wisconsin—Milwaukee, College of Nursing,
Milwaukee, Wisconsin
Tami Lile, DNP, MSN, BSN, Corporate Director of Nursing,
Vista College, Richardson, Texas
Lisa M. Pugsley, MSN, RN, CNE, CPN, Instructor of Nursing,
Georgia Gwinne College, Lawrenceville, Georgia

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Preface
Donna D. “Iggy” Ignatavicius
Purpose of this workbook
In just a few years, the National Council of State Boards of Nursing
(NCSBN) is expected to begin using the Next-Generation NCLEX®
Examination for nursing licensure based on its new model of clinical
judgment. This one-of-a-kind workbook is designed for students
enrolled in prelicensure programs in preparation for registered
nursing (RN) practice to help:
• Develop clinical judgment skills for professional nursing
practice to ensure patient safety and quality of care.
• Prepare for success on the Next-Generation NCLEX®
Examination (NGN) through practical thinking exercises in
which students apply clinical reasoning skills to make
appropriate clinical judgments.
This book is intended for students to use throughout their nursing
program. Thinking exercises are available for all major areas of
clinical specialty practice and are leveled from basic and
foundational to more complex and multisystem. Each exercise
provides challenging client situations with multiple NGN-style test
items. For many thinking exercises, the clinical situation evolves into
continuing care requiring the student to address changing client
conditions.

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Organization of this workbook
This student-friendly workbook is organized by nursing concepts
but is easy to use in any type of prelicensure RN nursing program. It
is divided into five distinct parts for a total of 30 chapters. Each
health problem throughout the book consists of between 4 and 7
thinking exercises for student practice:
Part 1 (Chapters 1 and 2). Chapter 1 provides an introduction
to clinical judgment as a primary skill needed by practicing
nurses. Chapter 2 offers tips for answering the practical
thinking exercises in the workbook.
Part 2 (Chapters 3 to 17). This section focuses on thinking
exercises that address nursing care for clients experiencing
commonly occurring medical-surgical, pediatric, and mental
health problems across the life span.
Part 3 (Chapter 18). This chapter provides multiple
opportunities for students to address the care of childbearing
women with uncomplicated and complicated clinical
situations. Care of the normal newborn is also included.
Part 4 (Chapters 19 to 28). This section includes thinking
exercises that address nursing care for clients experiencing
complex multisystem medical-surgical, pediatric, and mental
health problems across the life span.
Part 5 (Chapter 29 and 30). Although many pharmacology
thinking exercises are integrated throughout Chapters 3 to
28, Chapters 29 and 30 are dedicated solely to the nurse’s
role in administering commonly used drugs for adult and
pediatric clients who have commonly occurring and complex
health problems.
Answer Key. The last section of this workbook presents the
answers and rationales for each thinking exercise. In
addition, the student is provided with reference pages where
they can read more about each health problem.
References. At the end of the book is the list of textbook
citations that are used for reference for the thinking
exercises.

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About the author
Donna D. Ignatavicius received her diploma in nursing from the
Peninsula General School of Nursing in Salisbury, Maryland. After
working as a charge nurse in medical-surgical nursing, she became
an instructor in staff development at the University of Maryland
Medical Center. She then received her BSN from the University of
Maryland School of Nursing. For 5 years she taught in several
schools of nursing while working toward her MS in Nursing, which
she received in 1981. Donna then taught in the BSN program at the
University of Maryland, after which she continued to pursue her
interest in gerontology and accepted the position of Director of
Nursing of a major skilled-nursing facility in her home state of
Maryland. Since that time, she has served as an instructor in several
associate degree nursing programs. Through her consulting
activities, faculty development workshops, and international nursing
education conferences (such as Boot Camp for Nurse Educators®),
Donna is nationally recognized as an expert in nursing education.
She is currently the President of DI Associates, Inc.
(hp://www.diassociates.com/), a company dedicated to improving
health care through education and consultation for faculty. In
recognition of her contributions to the field, she was inducted as a
charter Fellow of the prestigious Academy of Nursing Education in
2007 and received her Certified Nurse Educator credential in 2016.

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Acknowledgments
Publishing a textbook would not be possible without the combined
efforts of many people. With that in mind, I would like to extend my
deepest gratitude to many people who were such an integral part of
this journey.
My contributing authors provided excellent manuscripts to
underscore the clinical relevancy of this publication. I give special
gratitude to Meg Blair, who was extremely valuable as a project
resource from beginning to end. The reviewers—expert clinicians
and instructors from around the United States—provided invaluable
suggestions and encouragement throughout the development of this
book.
The staff of Elsevier has, as always, provided us with meaningful
guidance and support throughout every step of the planning,
writing, revision, and production of this new title. Executive Content
Strategist Lee Henderson worked closely with me from the early
stages of this title to help me hone and focus the project from start to
finish. Senior Content Development Specialist Laura Goodrich then
worked with me from vision to publication.
Senior Project Manager Jodi Willard was, as always, an absolute
joy with whom to work. Her unwavering aention to detail,
flexibility, and conscientiousness helped to make this title
consistently readable while making the production process
incredibly smooth. Also, a special thanks to Publishing Services
Manager Julie Eddy. Designer Amy Buxton is responsible for the
beautiful cover and the interior design.
My acknowledgments would not be complete without recognizing
the dedicated team of Educational Solutions Consultants and other
key members of the Sales and Marketing staff who helped to put this
book into your hands.

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Exemplars
Medical-surgical nursing
Young adult
Burns, Exemplar 26, 163
Crohn’s Disease, Exemplar 11A, 70
Drugs That Affect Immunity, Exemplar 30B, 187
Drugs That Manage Emergencies, Exemplar 30D, 191
Drugs That Manage Infection, Exemplar 29E, 182
Intestinal Obstruction, Exemplar 24B, 152
Traumatic Brain Injury, Exemplar 21, 136
Middle-age adult
Acute Pancreatitis, Exemplar 25C, 160
Breast Cancer, Exemplar 10, 67
Cellulitis, Exemplar 12A, 77
Chest Trauma, Exemplar 23, 145
Cholecystitis/Cholecystectomy, Exemplar 7A, 44
Chronic Kidney Disease, Exemplar 24A, 149
Chronic Obstructive Pulmonary Disease, Exemplar 5B, 35
Crohn’s Disease, Exemplar 11A, 70
Deep Vein Thrombosis, Exemplar 4, 28
Diabetes Mellitus, Exemplar 9A, 61
Drugs That Affect Cloing, Exemplar 29B, 175
Drugs That Affect Immunity, Exemplar 30B, 187
Drugs That Affect Perfusion, Exemplar 29C, 177
Drugs That Manage Infection, Exemplar 29E, 182
Drugs That Promote Comfort and Metabolism, Exemplar 29D, 179

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Hyperthyroidism/Thyroidectomy, Exemplar 9B, 65
Management of Care: Complex Health Problems, Exemplar 28, 170
Myocardial Infarction, Exemplar 19A, 121
Osteoarthritis/Total Knee Arthroplasty, Exemplar 8C, 56
Parkinson Disease, Exemplar 8D, 58
Peptic Ulcer Disease, Exemplar 7B, 47
Uterine Leiomyoma/Hysterectomy, Exemplar 17, 98
Older adult
Atrial Fibrillation/Stroke, Exemplar 19B, 123
Benign Prostatic Hyperplasia, Exemplar 6, 40
Cataracts, Exemplar 13, 84
Cirrhosis, Exemplar 25B, 158
Delirium, Exemplar 14A, 87
Drugs That Affect Cloing, Exemplar 29B, 175
Drugs That Affect Nutrition and Elimination, Exemplar 29A, 173
Drugs That Affect Perfusion, Exemplar 29C, 177
Drugs That Affect Perfusion and Gas Exchange, Exemplar 30A, 184
Drugs That Manage Emergencies, Exemplar 30D, 191
Drugs That Promote Comfort and Metabolism, Exemplar 29D, 179
Fractured Hip/Open Reduction Internal Fixation, Exemplar 8A, 51
Heart Failure, Exemplar 3A, 21
Hypovolemic Shock, Exemplar 19C, 127
Intestinal Obstruction, Exemplar 24B, 152
Management of Care: Complex Health Problems, Exemplar 28, 170
Sepsis, Exemplar 22, 140
Traumatic Brain Injury, Exemplar 21, 136
Childbearing family
Uncomplicated Prenatal Woman, Exemplar 18A, 101
Complicated Prenatal Woman, Exemplar 18B, 105
Uncomplicated Intrapartum Care, Exemplar 18C, 108
Complicated Intrapartum Care, Exemplar 18D, 111
Uncomplicated Postpartum Care, Exemplar 18E, 114
Complicated Postpartum Care, Exemplar 18F, 116
Uncomplicated Newborn Care, 18G, 118

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Pediatric nursing
Appendicitis/Appendectomy, Exemplar 11B, 72
Asthma, Exemplar 5A, 32
Depression, Exemplar 15, 92
Diabetic Ketoacidosis, Exemplar 25A, 155
Drugs That Affect Perfusion and Gas Exchange, Exemplar 30A, 184
Drugs That Affect Nutrition and Elimination, Exemplar 29A, 173
Drugs That Manage Infection, Exemplar 29E, 182
Fractured Radius and Medial Epicondyle, Exemplar 8B, 53
Respiratory Syncytial Virus (RSV), Exemplar 12B, 80
Sickle Cell Disease, Exemplar 3B, 25
Spinal Cord Injury, Exemplar 20, 132
Substance Use Disorder, Exemplar 27, 166
Mental health nursing
Alzheimer’s Disease, Exemplar 14B, 89
Delirium, Exemplar 14A, 87
Depression, Exemplar 15, 92
Drugs That Manage Psychoses, Exemplar 30C, 188
Generalized Anxiety Disorder, Exemplar 16, 95
Parkinson Disease, Exemplar 8D, 59
Substance Use Disorder, Exemplar 27, 166
Pharmacology
Drugs That Affect Cloing, Exemplar 29B, 175
Drugs That Affect Immunity, Exemplar 30B, 187
Drugs That Affect Nutrition and Elimination, Exemplar 29A, 173
Drugs That Affect Perfusion, Exemplar 29C, 177
Drugs That Affect Perfusion and Gas Exchange Exemplar 30A, 184
Drugs That Manage Emergencies, Exemplar 30D, 191
Drugs That Manage Infection, Exemplar 29E, 182
Drugs That Manage Psychoses, Exemplar 30C, 188
Drugs That Promote Comfort and Metabolism, Exemplar 29D, 179

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1
Transitioning from the nursing
process to clinical judgment
Learning outcomes
1. Review the evolution of the nursing process and its
emphasis on the current NCLEX®.
2. Explain why the National Council of State Boards of
Nursing (NCSBN) is planning to add a focus on clinical
judgment for the Next Generation NCLEX® (NGN).
3. Identify the six cognitive skills of the NCSBN Clinical
Judgment Measurement Model (CJMM).
4. Compare the steps of the nursing process, stages of
Tanner’s Model of Clinical Judgment, and the six cognitive
skills of the NCSBN CJMM.
KEY TERMS
ADPIE
A five-step problem-solving approach that includes assessment,
diagnosis, planning, implementation, and evaluation.
clinical judgment

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Developing Clinical Judgment for Professional Nursing and the Next-Generation NCLEX-RN® Examination (2020)

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