NCLEX-PN clinical judgment practice questions, set 25
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 25
You notice cues, form a hypothesis, act, and evaluate — the same loop Next Generation items reward. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the NCLEX-PN exam guide or more NCLEX-PN practice questions.
Five clinical judgment questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
The nurse is caring for a client awaiting test results on a biopsy. The client is unconscious, and the physician informs the client's spouse that the biopsy came back positive for cancer. The spouse asks the nurse if they will not share this news with the client because they would prefer the client be unaware of the diagnosis. Which of the following responses is most appropriate?
A. "I will have a psychiatrist confirm whether the news will cause negative effects, and if so, I will comply with your request."?
B. "For ethical reasons, I am unable to withhold this information from the client."?
C. "You do not have the option to sign paperwork stating you are accepting the risk of not sharing this with the client."?
D. "You must have a durable power of attorney for healthcare advanced directive in place before I can consider this request."?
Show answer and rationale
Correct answer: B — "For ethical reasons, I am unable to withhold this information from the client."?
The correct response is, "For ethical reasons, I am unable to withhold this information from the client."? The ethical principle of veracity requires that the nurse is truthful with the client and does not withhold information even if it is requested by the family. Choice A is incorrect because seeking a psychiatrist's confirmation is not necessary to uphold the ethical principle of truth-telling. Choice C is incorrect as implying that signing paperwork overrides the nurse's ethical obligation to be honest with the client is inappropriate. Choice D is also incorrect as a durable power of attorney is not relevant in this situation where the spouse is asking the nurse to withhold information.
Question 2
A person who had a left CVA and right lower extremity hemiparesis is being instructed by a nurse to use a quad cane. Which of the following is the most appropriate gait sequence?
A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
Show answer and rationale
Correct answer: A — Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
The correct gait sequence for a person with left CVA and right lower extremity hemiparesis using a quad cane is to place the cane in the patient's strong upper extremity, which is the left upper extremity in this case. The correct sequence should be right lower extremity followed by left upper extremity, as this pattern mimics a normal gait pattern. Therefore, Choice A is the correct answer. Choices B, C, and D are incorrect because they do not follow the proper gait sequence for this specific patient's condition. The cane should be placed in the strong upper extremity, and the affected lower extremity should move first to provide stability and support, which is essential in this situation.
Question 3
While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. What should the nurse do?
A. Make the charge nurse on the unit aware of the situation so that they can take the necessary steps to maintain the confidentiality of the information being reported.
B. Disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
C. Return to their own unit and not disclose that confidential information has been overheard.
D. Ignore the situation.
Show answer and rationale
Correct answer: A — Make the charge nurse on the unit aware of the situation so that they can take the necessary steps to maintain the confidentiality of the information being reported.
To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation. This allows the charge nurse to take necessary steps to maintain confidentiality and ensure that the information is communicated in an appropriate and private manner. Disclosing the situation to the charge nurse is essential to address any breaches in confidentiality and uphold professional standards of privacy and ethics. Disregarding the information, returning to their own unit without disclosure, or ignoring the situation altogether would not address the breach of confidentiality and could lead to further issues regarding patient privacy and trust.
Question 4
A nurse is assisting with data collection on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, the client reports concern about sexual dysfunction. What should be the nurse's next action?
A. Document the client's concern in the medical record.
B. Report the client's concern to the health care provider.
C. Tell the client that sexual dysfunction is not a normal age-related change.
D. Ask the client about medications he is taking.
Show answer and rationale
Correct answer: D — Ask the client about medications he is taking.
Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. It is crucial to assess the medications the client is taking as they could be contributing to the reported sexual dysfunction. While documenting the concern and informing the healthcare provider are important steps, the immediate priority is to gather information on the medications that could be impacting the client's sexual function. Therefore, the nurse's next action should be to ask the client about the medications he is taking.
Question 5
In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's:
A. feelings about what has been described
B. thoughts about what has been described
C. possible solutions to the problem
D. intent in sharing the description
Show answer and rationale
Correct answer: B — thoughts about what has been described
In a psychosocial assessment, the nurse should progress from having the client describe problematic behaviors to eliciting their thoughts about the dilemmas. This step provides essential assessment data and insights into the client's interpretation of the situation. Asking about feelings, solutions, or intent in sharing the description is premature at this stage. Understanding the client's thoughts is crucial before delving into more complex emotional or problem-solving aspects. Therefore, the correct answer is to elicit the client's thoughts about the described behaviors and situations, as this helps the nurse gain a deeper understanding of the client's perspective and thought processes.
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Question 6
The Token Economy is a type of therapy that focuses on:
A. play therapy
B. behavior modification
C. milieu therapy
D. associative
Correct answer:
The correct answer is 'behavior modification.' The Token Economy is a form of behavior modification that involves providing positive reinforcement in the form of tokens or rewards for desired behaviors. This approach aims to increase the occurrence of positive behaviors by rewarding them. Play therapy (choice A) focuses on using play as a medium for therapeutic communication, not specifically behavior modification. Milieu therapy (choice C) involves shaping the environment to promote desired behaviors but is not the primary focus of the Token Economy. 'Associative' (choice D) is not directly related to the Token Economy or its focus on behavior modification, making it an incorrect choice.
A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?
A. Check with the case manager on duty about possible police intervention.
B. Provide an environment of concern and emotional stabilization.
C. Clean the patient's wounds with normal saline and gauze.
D. Refer the patient to a counselor specializing in trauma.
Correct answer:
In a situation where a patient describes a brutal assault and rape, the first priority should be to provide emotional support and create a safe and supportive environment. This helps the patient feel secure and cared for, which is crucial for their well-being at that moment. Checking with the case manager about police intervention should come after ensuring the patient's immediate emotional needs are addressed. Cleaning the patient's wounds, though important, can be secondary to providing emotional stabilization. Referring the patient to a counselor specializing in trauma is also crucial for long-term support, but the immediate focus should be on providing emotional support and stability.
Which of the following attitudes is essential in a nurse who assists clients during crises?
A. viewing crisis intervention as the first step in solving bigger problems
B. wanting to help clients solve all problems identified
C. taking an active role in guiding the process
D. feeling that work requires identification with all of a client's problems
Correct answer:
Viewing crisis intervention as the first step in solving bigger problems is essential in a nurse who assists clients during crises. This approach focuses on addressing the immediate crisis first, which can potentially prevent the escalation of bigger problems. Wanting to help clients solve all problems identified (Choice B) may not be feasible or necessary during a crisis situation where immediate intervention is crucial. Taking an active role in guiding the process (Choice C) is important, but the primary focus should be on crisis intervention. Feeling that work requires identification with all of a client's problems (Choice D) may lead to a lack of focus on the immediate crisis at hand.
Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
A. her response to hospitalization
B. the presence of a macular rash on her trunk
C. her cardiac status
D. the presence of polyarthritis and joint pain
Correct answer:
Monitoring Jackie's cardiac status is of the highest priority in a patient with rheumatic fever. Rheumatic fever can lead to permanent cardiac damage, making it crucial to closely monitor the heart. Assessing for signs of carditis, such as murmurs or other cardiac symptoms, is essential. The second priority is evaluating joint symptoms for the presence of polyarthritis and pain, which are common manifestations of rheumatic fever. While assessing Jackie's response to hospitalization is important for her emotional well-being, it is not the highest priority. The presence of a macular rash, although relevant, is not as high a priority as monitoring cardiac status or assessing joint symptoms.
The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the physician?
A. "I had chickenpox when I was 8 years old."?
B. "I had rheumatic fever when I was 10 years old."?
C. "I have a strong family history of gastric cancer."?
D. "I have pain in my hip with any movement."?
Correct answer:
The most important statement for the nurse to report to the physician is that the client had rheumatic fever when they were 10 years old. This information is crucial as individuals who have had rheumatic fever require pre-medication with antibiotics before any surgical or dental procedure to prevent bacterial endocarditis. Reporting this history ensures the client's safety during the hip replacement surgery. The other options, such as having chickenpox in the past, a family history of gastric cancer, or experiencing hip pain, are important for the client's overall health assessment but do not have the same immediate implications for the upcoming surgery as the history of rheumatic fever.
Levothyroxine (Synthroid) is the drug of choice for thyroid replacement therapy in clients with hypothyroidism because:
A. it is chemically stable, nonallergenic, and can be administered orally once a day.
B. it is available in a wide range of concentrations to meet individual client requirements.
C. it is a prodrug of T3.
D. it has a long half-life.
Correct answer:
Levothyroxine (Synthroid) is the preferred medication for hypothyroidism due to its chemical stability, nonallergenic properties, and convenient once-daily oral administration. It is safe and effective with minimal side effects when appropriately dosed. Choice B is incorrect because while Levothyroxine is available in various concentrations, it is not the reason it is the drug of choice; the primary reason is its stability and nonallergenic nature. Choice C is wrong as Levothyroxine (T4) is not a prodrug of T3; it is converted to T3 in the body. Option D is inaccurate because Levothyroxine has a long half-life (around 7 days), enabling once-daily dosing, as opposed to a short half-life.
When assessing a client with terminal cancer receiving a continuous intravenous infusion of morphine sulfate, what should the nurse check first?
A. Temperature
B. Respiratory status
C. Pulse
D. Urine output
Correct answer:
When assessing a client with terminal cancer receiving morphine sulfate via continuous intravenous infusion, the nurse's priority should be checking the client's respiratory status first. Morphine sulfate can lead to respiratory depression, emphasizing the need for close monitoring of breathing. While temperature, pulse, and urine output are all essential components of the assessment, ensuring adequate respiratory function takes precedence due to the potential risk of respiratory depression associated with morphine sulfate. Promptly assessing respiratory status enables early identification of any signs of respiratory distress or depression, allowing for immediate intervention if needed.
A patient has fallen off a bicycle and fractured the head of the proximal fibula. A cast was placed on the patient's lower extremity. Which of the following is the most probable result of the fall?
A. Peroneal nerve injury
B. Tibial nerve injury
C. Sciatic nerve injury
D. Femoral nerve injury
Correct answer:
The correct answer is peroneal nerve injury. The head of the proximal fibula is in close proximity to the peroneal nerve, making it susceptible to injury when there is a fracture. The peroneal nerve runs along the fibula and can be affected by trauma to this area. Choice B, tibial nerve injury, is incorrect as the fracture site is closer to the peroneal nerve, not the tibial nerve. Choice C, sciatic nerve injury, is incorrect as the injury is more localized to the fibular head area where the peroneal nerve is affected. Choice D, femoral nerve injury, is incorrect as the femoral nerve is not immediately adjacent to the proximal fibula and is not typically affected by this type of injury.
Which of the following substances need to be assessed when completing a family health assessment?
A. coffee, tea, cola, cocoa, and other substances
B. alcohol, tobacco, and illegal substances
C. medicines prescribed by a physician
D. all of the above
Correct answer:
When completing a family health assessment, it is essential to assess all substances consumed by family members, including coffee, tea, cola, cocoa, alcohol, tobacco, illegal substances, and medicines prescribed by a physician. Understanding the complete picture of substance use within the family is crucial for identifying potential health risks and providing appropriate care. Choice D, 'all of the above,' is the correct answer as it encompasses the comprehensive assessment of all substances. Choices A, B, and C are incorrect as they only present partial aspects of substance assessment and do not cover the full range of substances that should be evaluated in a family health assessment.
A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) following an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?
A. increased platelet count
B. increased fibrinogen
C. decreased fibrin split products
D. decreased bleeding
Correct answer:
In the context of DIC, effective Heparin therapy aims to halt the process of intravascular coagulation. One of the indicators of a positive response to Heparin therapy is an increase in fibrinogen levels. Heparin interferes with the conversion of fibrinogen to fibrin by thrombin. This interruption helps increase the availability of fibrinogen. While the platelet count may increase due to improved clotting, the primary focus of Heparin therapy is on fibrinogen. Fibrin split products are expected to decrease as the coagulation cascade is controlled. Although decreased bleeding is an ultimate goal, the immediate effect of Heparin is not directly on bleeding but on the coagulation process.
NCLEX-PN clinical judgment practice questions, set 25 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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