hi I'm Melanie from you world we're looking at next-gen practice questions from the world question Banks all right so looking at an actual ngn style case study from you world here what I want to start talking about first is the clinical judgment measurement model it serves as the foundation for all of this ngn new style content so here we have this is kind of a mock-up to make it easy to understand what this means but to really understand it in depth there's a link over here you can go to to the ncsbn website and they are the ones who created the clinical judgment measurement model from the ncsbn so here we kind of have a little on the green and blue side on the left um you can see that this is what and we want to focus on the word measurement here so they created this to help measure nursing students clinical judgment and so that's the basis for the ngn content now if you look over on the right side you can see that it kind of like follows the nursing process in a way but the nursing process of course is focused on like what do we do as nurses when we're taking care of patients whereas the clinical judgment measurement model is testing how well you can move through these steps in making decisions at the bedside so starting at the top recognizing cues just means like can you notice the stuff that you need to notice to make decisions analyzing cues means that like can you take those pieces and pick out what's important and put it together prioritizing hypotheses is taking that information putting it together and then deciding what's most important here generating Solutions is then what can I do about this taking action is let's do it now how do I do it and then evaluating outcomes is did it work should I do something different and then we kind of just continue in this continuous cycle just like the nursing process it goes as a just a continual Loop of like taking care of your patient is like checking things out intervening did that work over and over again so it kind of mimics that but the purpose is different this is for testing understanding of clinical judgment so with that in mind when we look at a case study itself the idea is that each question in the case study is going to try to hit one of these steps so they can measure how are you doing as a student matching up with each of these steps of the clinical judgment measurement model are you hitting each of these which is why you can see here that this is a six step model and there's six questions in a case study so let me flip over so the nurses notes tab here gives us some good information to start with we can tell they're in the emergency department it tells us that it's 8 am 800 hours that may or may not be important and then we can see here the client has come in due to fear of having a heart attack heart attacks of course are you know one of the most emergency conditions you can walk in with the client states I was taking a bus from home we'll just kind of read it over briefly here um chest tightness they had some help and there's some fear here of what happens next time if they can't find help and then they're saying that they have had some similar experiences recently it's kind of random and they're afraid of what's going to happen if it happens again and if they'll have help so then looking over of course we have a lot of clinical data here so we're going to go from the nurses notes Tab and make sure we're looking at all the information here's the history and physical tab this has a lot of helpful information in it so these are typically written by your health care provider here and this is going to tell us a lot about their physical symptoms so generally we can see that this client even though we're not looking at them we can tell from the notes that they are well groomed taking care of themselves but having some minimal eye contact and appearing fidgety tearful a flat affect which is something that can be associated with depression and some other conditions so definitely some maybe some mental health issues here we want to be sensitive to the client is trembling uh the thought process is logical that's helpful to know and no reports of suicidal or homicidal ideations that's great definitely something we want to always screen for with mental health concerns cardiovascular is important here because they're reporting chest tightness um we've got Random episodes of chest pain some dizziness which could be you know concern for perfusion if they're being dizzy uh shortness of breath heart palpitations that have been um happening and stopping over a few months uh spontaneous resolution of pain um they're having some weight loss which there's a bunch of different reasons you can have that thyroid issues or just depression or um other mental health stuff and then we see here they drink alcohol socially so that's not something that's jumping out to us the client reports having a glass of wine with the evening meal yesterday so none of that's really jumping out for like recycled there um and then just making sure we don't miss anything here's the vital signs tab so this patient right now same time we can see it's also still 8 am here with this note um temperatures 99. a little bit elevated but I wouldn't say they're febrile right now um getting close to tachycardic here but she could be due to anxiety respiratory status is totally fine 1898 on room air that's great blood pressure is great so now we kind of have this picture in our head of how they're doing physically and mentally let's go over and start looking at the questions so this is the first of six um which of the following findings requires immediate follow-up and then we select all that apply one of the nice things about this item is that it's actually a traditional item you've seen these items before on your tests in nursing school and as we know the questions that are inside of a case study can be any item type they can be some of those newer ones which are a little intimidating or they can just be these traditional items that you're used to seeing so that's kind of nice here because this is an item that we've seen this before so let's go through one by one and you know we can see here this word immediate is bolded so we're not talking about like hey yeah we want to make sure that they're going to discharge with this information we're focusing on what's going on right now so let's pick out those cues here and see what we find select all that apply so chest tightness absolutely that's something we want to follow up on right now there's some scary things that are related to chest tightness flat affect that's definitely a concern for like a mood disorder or there's some other neurological disorders that can cause that but like it's not my primary focus maybe not heart palpitations that's another cardiac when we're thinking ABCs that's way up there minimal eye contact that also feels like a mental health issue that we definitely want to follow up on but like right now it's probably not our highest priority shortness of breath absolutely ABCs This Could Be perfusion this particularly it could be because of a respiratory issue a lot of reasons that this can be scary weight loss this has been over the first or I think it's in the last couple weeks or some extended amount of time so this is not our our primary concern right now so go ahead and hit submit now because this is a case study um in our study product you're not going to see the answers right away because the answers are the answers to the question and the explanation because that would just totally give away the next question so we're going to hold off on that and come back to it because we definitely want to learn from what we've answered this question with here so moving on to the next one so item number two of six and we're looking over here it doesn't say that there's new exhibit information and we can see over here that it's the same three as before sometimes We'll add a new time interval here to the nurses notes or the vital signs they haven't done it in this situation and if they had done it they would have told us over here so we don't need to look at the notes again we can just focus here on what the item looks like so one of the newer ngn item types this is a multiple response Matrix item so going into this question we know that it's multiple response so I could go ahead and I could click every single answer try to get as many points as I could but they would knock off points for the incorrect answers so we want to focus in and make sure we're only clicking the correct answers because they're going to subtract a point if we select the wrong ones so looking at it the best way to think about it really is column by column so let's just focus here we're comparing hyperthyroidism myocardial infarction heart attack and then panic disorder so let's go one by one starting with hyperthyroidism what are the findings that would be associated with that you know it says here they may support more than one disease process so we know that diaphoresis it doesn't just end up in one of these spots it could be on all three of them so diaphrases meaning sweating definitely with hyperthyroidism they have hot flashes they have poor um so they have more sensitivity to heat and poor ability to to cope with with the heat like if they're outside in the summer or they're just in a situation that's giving them a lot of heat they don't cope with that very well Trembling Hands absolutely that's related to hyperthyroidism because of the hormone imbalances and then also heart palpitations here absolutely is related to one of the thyroid conditions sometimes I feel like I get hung up on hypo versus hyperthyroidism hyper here meaning a lot of extra so they have hyper extra thyroid hormone and when you have extra you're more stimulated and you do have heart palpitations so we want to click that one and I believe shortness of breath is also that one I'm kind of I need to think about that some more some more so let's move on to the next column myocardial infarction diaphoresis is absolutely one of those subtle signs that people don't always realize you know a little bit of heartburn and some sweating it feels like it's kind of random but maybe not a big deal but it's actually one of those subtle signs of a heart attack so absolutely we want to remember that one and recognize that that's one of the appropriate things to click here with myocardial infarction Trembling Hands it doesn't feel like particularly characteristic of my I'll leave that one off heart palpitations absolutely this is a cardiac problem they're gonna feel some some flutters and some weird stuff going on shortness of breath absolutely there's a big issue here with perfusion when you're having an infarct in your heart you're not getting that oxygen where it needs to be and so you're going to become short of breath and then thinking about shortness of breath here absolutely that's related you know when you're having an infarct in your myocardial tissue you're not getting perfusion to your heart your heart's not working like it's supposed to be the blood's not moving forward as well as it's supposed to be and so absolutely shortness of breath is something that you could see with that that's definitely one you want to follow up on all right and then panic disorder so this is more a mental health issue and so the physiological stuff going on is more related to how these hormones our body is releasing like adrenaline how it's affecting us so it doesn't mean that you know shortness of breath I would absolutely say is related does that mean we're having a respiratory problem no but we're having a situation where our body is saying like oh it's it's time to panic it's time to go something needs to happen we're short of breath because our body's getting ready to do something because we're feeling that anxiety of panic heart palpitations also definitely related to panic disorder you know with the flood of stress hormones you're having a lot of people do report chest discomfort so they'll have that feeling of like flip-flopping in their chest and that you know we call that heart palpitations um also diaphoresis again similar related to the same thing you're going to see some sweating so that would be related as well trembling I think that's related I mean you're feeling really freaked out and people get trembly when that happens uh okay so then let me just double check what we're missing here this one's empty okay that's okay and then hyperthyroidism this one's empty I feel like they might be shorter breath especially because we know that with temperature dysregulation and they do have elevated temperature shortness of breath is sometimes this thing the body does to kind of compensate for that so kind of releasing more air breathing faster breathing faster they may feel like shorter breath so I feel like we could click that one and see how we go so let's go ahead and submit and again we won't see the explanation just yet so we'll move on to the third question a lot to think about with this all right item three out of six and we can see here that something else has popped up and then also it tells us right here the nurse has reviewed the information from diagnostic results and laboratory results so we want to make sure we're checking out this tab scan so coming over here we've got laboratory results and as we know troponin is one of the Hallmark Labs that tells us whether or not somebody's having a heart attack so here with troponin it looks like they've tested two different types I don't know exactly the difference but I know that troponin is a test they do to tell me whether or not they're having an acute myocardial infarction situation so I can see here they do give me the reference ranges so I know that a troponin value here of more than this is going to be concerning because the normal value is less than 0.1 so anything that's above that would be concerning this person's value is 0.0 0. so the normal being less than 0.1 we're in that safe range we've got a normal value for this troponin and then the same here they're at zero the normal is less than .03 so I feel like really ruling out here heart attack is the cause of this person's symptoms so again we're going through the clinical judgment measurement model we've analyzed the cues and now we're kind of prioritizing like what is going on and what do we do here and then we need to also make sure we look at the diagnostic results so looking at diagnostic results here the ECG is showing that they're in sinus tachycardia we already knew they were in tachycardia we looked at their Vital Signs and their heart rate was elevated so and this is not one of those findings like um there are certain you know ST segment elevation and other arrhythmia findings that would tell the provider that there's a potential for a heart attack here and they're really the ones to look at that and and make decisions most of the time but here we know at least that this is something we already knew was going on and it's not one of those Hallmark scary arrhythmias that would make us think heart attack so we've kind of ruled out heart attack which is great all right moving over to look at item three here it's asking us to complete the following sentence by choosing from the list of options so the nurse recognizes the client is at highest risk so again we have that bolded word and highest telling us that this is the most one we want to focus on it's a priority here that doesn't mean that the other ones aren't potential answers but we're focused on the most important here which makes sense because this is the prioritizing hypotheses question in our clinical judgment measurement model so highest risk for developing blank as evidenced by blank so here let's look at our options and see what we can pick from so we think they're at highest risk of heart failure agoraphobia or thyroid storm here with this patient I think from everything we've read in their history and physical especially I feel like we're leaning towards a mental health issue with their affects and then they're not reporting a lot of GI distress that people can have with thyroid issues like especially you know bad hyperthyroidism so I think we can kind of rule out the heart failure because we already know it's not cardiac and I think we can go away from the thyroid issue right now I think we're going to focus on the mental health condition so here I would say the most related mental health condition here is agoraphobia so I think that's going to be our answer for what their highest risk for because they're having those panics in situations and it seems to be they're on a bus when it happens so maybe it's related to being around people so let's click that as our concern for like a complication or a future problem they may develop and then as evidenced by blank so let's see where our options are here uh fear of future attacks they absolutely have that we saw that and then Evans by chest pain and palpitations well that's definitely related to panic attacks but if we're trying to support our answer of agoraphobia that may not be the best and then hear recent weight loss and loss of appetite so again with this type of question our first blank has been answered and so the second blank is needing to support what we've answered in the first link so we really need to focus on this wording as evidenced by blank so really what tells us that agoraphobia is going to be the answer and that I feel like is fear of future attacks because when you get around a group um and you have an anxiety I think is characteristic of agoraphobia so I think we're going to go ahead and click fear of future attacks because it seems most related all right and again we'll come back for the explanation here so moving on we got question number four so we're over halfway there and we're moving on in the measurement model to the stage of generating Solutions now and then we have this little alert here again that says the nurse has reviewed the information from nurse's notes so we know they've added more information there's not a new tab here but if we scroll down on the nurses notes we can see there's a new time frame so it was 8 AM and now it's 9 A.M an hour later uh we're evaluating the client they look irritable fidgety Restless uh still organized and logical thought process uh anxiety is sixth on a scale of zero to ten and then we're giving them a benzo to help with anxiety so that's alprazolam is one of the benzodiazepines so that's going to help with anxiety so we're going to go ahead and give them that medication here and then other Solutions we can provide that's what we want to focus on with these questions what else can we do to help this client right now um so here we're going to say for each potential intervention click the intervention as indicator or contraindicated so this is again a matrix item but it's a multiple choice Matrix which means that there's one answer for every row so that you're telling us give us one answer in every single row which helps us understand that they're not going to take away points if we click the wrong option because they're telling us you need to put an answer at every row so this is one of those where they give you points for every right answer but they don't take away points because they've already said we want five answers so give us five answers please so just kind of think about that as we go through here so one potential intervention is encouraging the use of positive self-talk I think that's appropriate this person again if they're having some mental health issues could benefit from that I think a lot of people can benefit from that so I would say that that's indicated so we would click this column and I think it's helpful to kind of treat each row as a separate question here so then we're going to go on to the next one and it says ask the client about any recent life stressors so is it good to bring it up right now is it therapeutic to talk about that um I think generally when we read about therapeutic communication we want to help the client open up about this kind of thing so I think it's probably indicated we'll click that um assist the client to recognize physical symptoms of anxiety this is absolutely helpful because here we've given our benzodiazepine if they walk away with a prescription for that medication they're going to need to know when to take it so having them understand like what is it that's like a precursor a sign that this may be coming a panic attack can we recognize those signs so this is a really important I think a great nursing driven intervention here is we want to make sure they can understand when this if this happens again um encouraging the client to spend some time alone and feeling anxious oof that one's tricky should they be alone when they're anxious if they're for considering agoraphobia that one's kind of difficult um I don't think we want to do that I think we want to encourage support systems is what we usually read about in our Nursery textbooks but then again if they're going to be agoraphobic I'm not sure about that one I think being alone can be relaxed let's click indicated not sure and then reinforcing abdominal breathing exercises to use for anxiety that's very much something that's appropriate for most people um so this is a great situation to use that Intervention which I think is why it's an important option here because this is something they can do when they're feeling that Panic coming on and the medication maybe isn't available or they haven't taken it and they just this is something they could sit down and do and if we teach them this then it can help them in the future so I would say that's absolutely something we want to do so we answered all five rows perfect move on to the next one all right item number five six we're getting close um it says the nurse reviews information from nurses notes and Vital Signs so we know we've got some more information to look at let's scroll down further on the nurses notes it says here a couple hours later the client rates exact rates anxiety as two on a scale zero ten that's great so we've come down from a six to a two and they want to go home they're ready to go home the client is referred to an outpatient mental health clinic for follow-up that's perfect because it is a nurse's job absolutely to make sure that we're not just hey here's a Band-Aid now you can go home this is a we want to make sure that this chronic condition is going to be carried through with further treatment so we want to make sure hey do you have the phone number for the clinic you need to go with do you have an appointment set up yet this is something when you're discharging a patient this is the nurse's job you need to make sure that this is happening so here we say the client is referred to the clinic perfect we can check that box and then our other new information that we got here was under the vital signs so we can compare the 8am vitals to the 11AM vitals and see that with the anxiety going down things have really normalized here the respirations have gone down they're still sadding really well everything else is getting much more normalized which is great which is another good indication that they are getting close to a discharge all right so looking at the item here we're saying the nurse is reinforcing teaching about newly prescribed medications so we've got Alprazolam which is again that benzodiazepine which helps acutely with anxiety that when you're really feeling the symptoms and then Sertraline which is going to be a long-term medication that you take scheduled at the closest time possible every day to reach a steady state of that medication in your bloodstream it's an SSRI so it's an antidepressant it's going to help with depression anxiety um so we've got two new medications they're similar in drug in the category of treating mental health similar in that way but they're taken very differently so we need to say here which or we need to read here which of the following statements by the nurse are appropriate to include in the teaching so what do we say to our patient here to make sure they understand select all that apply again this is one of the older item types so that's helpful because it's not one of the new or more intimidating ones for option one here it's saying avoid driving after taking out prasolam that's a great thing to teach about it is definitely a nursing intervention because it's very safety focused if you take a benzodiazepine and then get behind the wheel there's this risk of the sedative side effect causing an accident they usually talk on the prescription bottle as well they say you know don't drive or operate heavy machinery when you're taking this medication because it's dangerous so this is something we want to drill in and make sure they understand that if you take this medication for your anxiety it could you make you sleepy and then it could be dangerous to to drive a car so we're going to click that one um and then contact your healthcare provider immediately If you experience Suicidal Thoughts this is very important as we all know when you first start taking an antidepressant you can quickly get to this period of like you know kind of euphoric you're feeling more energy you're feeling better which is great but if you're still kind of depressed this can lead you to have more energy to act on a potentially suicidal action so here and this is particularly relevant in the younger group of people that's when they see it more so this patient's 21. so this is something we absolutely want to make sure it gets across is that you're taking a new SSRI there's this potential for this you know very devastating complication here so we want to drive home that hey if you're starting to have those Suicidal Thoughts when you're which happens kind of that initiation period of taking the medication contact your healthcare provider because that's not normal it's not a long-term side effect of the medication so they really need to know that right now to look out for that so we definitely want to cover that with this patient um do not abruptly stop taking Alprazolam because you may experience withdrawal [Music] that one is true that one I'm less confident on let's click it um lemon alcoholic beverages to know more than one drink a day while taking Alprazolam that was a little tricky because I think they're not supposed to drink at all when they take out but limiting is good if it's a concern because both alcohol and this benzodiazepine are going to be sedating which is why we're concerned about it I'm not going to click it because I'm wondering if they shouldn't have any so instead of one it should be none so I'll leave that one off for now but I'm kind of hung up on it we'll see and then option number five takes Sertraline at the onset of a panic attack that's that's wrong we know that ssris like I said they need to be taken at the same time every single day because they help prevent um so taking this you may be taking too much of it which can cause complications if you're taking it right at the onset of panic attack so that's incorrect teaching for this um so we're definitely going to leave that one off because I feel pretty confident that's wrong so looking back we've got three selected this is a multiple response it doesn't tell us how many to click which means that if we get an option wrong they're going to count off a point so I really want to be careful here limit alcoholic beverages so I'm on the fence I'm not going to click it because I don't want to lose a point all right submit all right moving on to the last question here in our case study it doesn't say we've gotten any new information I don't see any new tabs over there so I think we're looking at a future time interval so the client returns to the mental health clinic for a one month follow-up visit which is great because I love it when we can also see like what is this looking like long term which client statement would indicate that the client requires additional therapy to cope with panic disorder so this is a single best question so there's only one right answer which is really helpful um let's read here I realize that my panic attacks um are under control I'll eventually need to be tapered off I purchased a watch that alerts me when my heart at respiratory rate increases so I can be on breathing exercises that sounds like good I'd say they don't need additional therapy if they're doing this that sounds like something they should be doing it's probably helpful um my support group has been helping to identify what my thoughts are not realistic so I can talk myself out of feeling the Panic that's really helpful I mean having someone else help you realize when you're spiraling is great so I don't think that needs additional there hey it's great I think maybe they're doing well um taking the bus has been a trigger for me so my boss is letting me work from home wow that may not be their ideal you know we don't want them to necessarily have to sequester themselves at home because of their medical condition so that may mean that there's opportunity for them to progress more I mean it's great that their boss is being flexible but is that what they want long term taking the bus this is kind of one to mull over a little bit trigger for me yeah they're having to request accommodations from their job because their mental health condition is holding them back so I would say that this is something that maybe they could progress with so I think I think that's the right answer we'll go with that so we'll submit and then we can finally see the explanations which is great let's go ahead and move backwards though because this is item six of six and we want to see all the explanations uh for you world we have them of course for every single question so we can go back a little bit and see um here's the explanation for this so we'll talk through why every single option is right and wrong um we got scored three out of three that's great because this is one of those where we could have gotten points knocked off and we didn't which is awesome if you want to know more you can click this little thing scoring rule there's a little infographic about how that works we did great for this one um for our multiple response Matrix thing we got them all right um and this is another one where you could have gotten points knocked off so there's that same scoring rule information there and it tells us 11 out of 11 we got the max points which is great item number three again oh it's right this is a zero one which means that because they told us we had to have two responses they weren't going to take away points but we got both points which is great uh another Matrix okay this one I think we hovered over for a bit um do it is let's see so this was wrong so the correct answer was contraindicated okay so they're not supposed to be alone when they're feeling anxious they're supposed to reach out for a support system so but they told us we had to have one option for every one answer for every row so they're not going to take away points which means that we got four out of five so one two three four and they didn't subtract a point even though we got that one wrong so four out of five that's great and then number five here another SATA we got three out of three which is great so overall we did pretty pretty good for this case study and then when you are studying and taking your time obviously we want to highly encourage you to go through and read even if you got the answer right why like understanding the why behind the correct and the incorrect options is really that learning opportunity here so as you work through these I would definitely encourage you to start again from item number one and read your explanations because that's where the the learning is really gonna be reinforced and that's it for this case study whether you're taking a current NCLEX or the Next Generation NCLEX coming on April 1st 2023 practicing ngn questions will help you prepare for the exam and bedside practice visit nursing.uworld.com for more information and to see our options for RN and PN and to start practicing today