Clinical Judgement Practice 1

Individual Performance Profile RN 3.0 Clinical Judgment Practice 1 Individual Name: Individual Score: Student Number: Practice Time: Institution: Program Type: Test Date: Individual Performance in the Major Content Areas # Individual Points Score Highlight Text 3 100.0% Multiple Response Select All That Apply 6 100.0% Drop Down Cloze 2 100.0% Drop Down Rationale 1 100.0% Matrix Multiple Choice 6 100.0% Sub-Scale Matrix Multiple Response 17 94.1% Multiple Response Select N 4 100.0% Individual Score (% Correct) Outcomes Clinical Judgment No of Points Individual Score Description Recognize Cues 4 100.0% Filter information from different sources (i.e., signs, symptoms, health history, environment). Identify relevant information related to the client’s condition. Use knowledge, experience and evidence to assess clients. Use verbal, nonverbal, written, and electronic modes of communication. Recognize relevant subjective/objective client data. Identify subtle and apparent changes in client condition and related factors. Analyze Cues 23 95.7% Link recognized cues to a client’s clinical presentation and establishing probable client needs, concerns, or problems. Compare client findings to evidence-based resources and standards of care. Analyze expected and unexpected findings in health data. Anticipate illness/injury and wellness progression. Identify client problems and related health alterations. Analyze client needs. Identify potential complications. Identify how pathophysiology relates to clinical presentation. Identify data that is of immediate concern. Prioritize Hypotheses 3 100.0% Establish priorities of care based on the client’s health problems (i.e. environmental factors, risk assessment, urgency, signs/ symptoms, diagnostic test, lab values, etc.). Organize client assessment information according to changes, patterns and trends. Use standards of care and empirical frameworks for priority setting. Establish and prioritize client problems/needs based on the analysis of information and factors. Take Actions 3 100.0% Implement appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client’s health. Promptly and accurately perform nursing actions based on prioritized client problems. Implement a plan of care in collaboration with members of the interprofessional health care team. Implement a plan of care in collaboration with the client and care partners. Accurately document client care data and information. Incorporate client preferences and needs when performing nursing actions. Provide education to the client and/or care partner(s) regarding their health condition and care management. Participate in coordination of care with the client and healthcare team. Monitor the client’s response to interventions. Evaluate Outcomes 6 100.0% Evaluate a client’s response to nursing interventions and reach a nursing judgment regarding the extent to which outcomes have been met. Reassess client condition to determine achievement of expected outcomes. Evaluate efficacy of nursing actions determine if client outcomes were met. Modify client outcomes and/or nursing actions based on the client’s response and clinical findings when indicated. Update and revise the plan of care. Score Explanation and Interpretation Individual Performance Profile ITEM SCORING ATI follows NCSBN guidance for item scoring. Accordingly, each item is worth one or more points. Depending on the item-specific scoring method, a student’s response may earn full, partial, or no points. INDIVIDUAL SCORE The individual score is the number of points received divided by the number of points on the assessment. It is on a scale of 0% to 100%. TOPICS TO REVIEW Based on the questions missed on this assessment, a listing of content areas and topics to review may be provided. A variety of learning resources may be used in the review process, including content, images, animations, and videos in ATI’s Content Mastery Series® Review Modules, online practice assessments, and a focused review that is individualized to the questions missed.