RN exams clinical judgment practice questions, set 115
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 115
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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
A nurse working in a rehabilitation unit is caring for a client who has dysphagia and has difficulty swallowing during meals. Which of the following actions should the nurse take to prevent the client from aspiration while eating?
A. Add liquid to foods to thin consistency.
B. Tilt the client\'s head slightly backward.
C. Offer verbal support while the client is eating.
D. Encourage socialization with others during meals.
Show answer and rationale
Correct answer: C — Offer verbal support while the client is eating.
The correct answer is C: "Offer verbal support while the client is eating." This action is important in preventing aspiration in a client with dysphagia as it helps the client stay focused on their eating and swallowing, reducing the risk of choking. Providing verbal support can also help the client feel more comfortable and confident during meals, which can contribute to safer eating practices. Adding liquid to foods to thin consistency (option A) may not be appropriate for all clients with dysphagia and should be based on individual swallowing assessments. Tilting the client's head backward (option B) can increase the risk of aspiration. Encouraging socialization with others during meals (option D) may distract the client from focusing on their eating and swallowing, potentially increasing the risk of aspiration. Therefore, offering verbal support is the most suitable action to prevent aspiration while the client is eating.
Question 2
.A client with major depressive disorder expresses feelings of hopelessness. Which nursing intervention should the nurse implement to address these feelings?
A. Encourage the client to engage in physical activity.
B. Provide opportunities for the client to make decisions.
C. Help the client identify positive aspects of their life.
D. Encourage the client to verbalize feelings of hopelessness.
Show answer and rationale
Correct answer: C — Help the client identify positive aspects of their life.
The correct answer is C: 'Help the client identify positive aspects of their life.' When a client with major depressive disorder expresses feelings of hopelessness, it is essential for the nurse to focus on helping the client see the positive aspects of their life. This intervention can help shift the client's perspective from a negative and hopeless outlook to a more balanced view. Encouraging physical activity (A) may be beneficial, but it may not directly address the underlying feelings of hopelessness. Providing opportunities for decision-making (B) can empower the client, but it may not specifically target the expressed hopelessness. Encouraging the client to verbalize feelings of hopelessness (D) is important for communication but may not effectively address the root cause of the hopelessness. Therefore, helping the client identify positive aspects of their life is the most appropriate intervention in this situation.
Question 3
A school nurse who is teaching a health course at the local high school is presenting information on human development and sexuality. When talking about the role of hormones in sexual development, which hormone does the nurse teach the class is the most important for developing and maintaining the female reproductive organs?
A. estrogen
B. progesterone
C. androgens
D. follicle-stimulating hormone
Show answer and rationale
Correct answer: A — estrogen
The correct answer is A: "estrogen." Estrogen is the primary female sex hormone responsible for the development and maintenance of the female reproductive organs, such as the uterus, fallopian tubes, and vagina. It plays a crucial role in regulating the menstrual cycle, promoting secondary sexual characteristics like breast development, and preparing the uterus for pregnancy. Progesterone, while important for pregnancy support and maintaining the uterine lining, is not the primary hormone for developing and maintaining female reproductive organs. Androgens are male sex hormones, and while present in females in smaller amounts, they are not primarily responsible for female reproductive organ development. Follicle-stimulating hormone (FSH) is a pituitary hormone that plays a role in stimulating ovarian follicle growth and maturation but is not the primary hormone for developing and maintaining female reproductive organs.
Question 4
.A nurse is assessing a client who has been diagnosed with anorexia nervosa. Which of the following findings should the nurse expect?
A. Weight gain and increased appetite
B. Lanugo on the face and back
C. Increased body temperature and tachycardia
D. Hyperactivity and distractibility
Show answer and rationale
Correct answer: B — Lanugo on the face and back
The correct answer is B: 'Lanugo on the face and back.' Lanugo is fine, downy hair that develops on the face and back as a result of malnutrition in individuals with anorexia nervosa. This finding is a characteristic feature of severe and prolonged malnutrition. Weight gain and increased appetite (A) are not typical findings in anorexia nervosa, as individuals with this condition often experience significant weight loss and a decreased appetite. Increased body temperature and tachycardia (C) may occur in some cases of severe malnutrition, but they are not specific to anorexia nervosa. Hyperactivity and distractibility (D) are not typical manifestations of anorexia nervosa; instead, individuals with this disorder may exhibit lethargy and fatigue due to inadequate nutrition. Therefore, the presence of lanugo on the face and back is a key finding that the nurse should expect when assessing a client with anorexia nervosa.
Question 5
A nurse is providing discharge teaching to a client who is postpartum and is breastfeeding. Which of the following instructions should the nurse include?
A. Feed the newborn every 4 hours.
B. Apply warm compresses to the breasts after each feeding.
C. Wear a supportive bra throughout the day and night.
D. Pump the breasts twice daily.
Show answer and rationale
Correct answer: C — Wear a supportive bra throughout the day and night.
Option C, 'Wear a supportive bra throughout the day and night,' is the correct instruction to include in discharge teaching for a postpartum client who is breastfeeding. Wearing a supportive bra helps provide comfort and prevents sagging of the breasts. It also helps to reduce discomfort and potential engorgement. The continuous support from a well-fitted bra can aid in maintaining breast shape and prevent issues such as mastitis. Options A, B, and D are not appropriate instructions for a breastfeeding mother. Feeding schedules for newborns should be on-demand rather than every 4 hours, warm compresses may increase milk supply unnecessarily or cause discomfort, and pumping twice daily without a specific reason may interfere with establishing a good breastfeeding routine. Therefore, the most relevant and beneficial advice for the postpartum breastfeeding client is to wear a supportive bra throughout the day and night.
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Question 6
What are the qualities that define a leader who uses laissez-faire?
A. The group in planning and in decision making
B. Passive and puts the responsibility of decision-making to others.
C. Foster independence in team by promoting motivation and creativity.
D. Provide little autonomy and self-motivation.
Correct answer:
The correct answer is B because a leader who uses laissez-faire leadership style is passive and tends to delegate decision-making responsibilities to others within the group. This style of leadership involves minimal interference from the leader, allowing team members to make decisions independently. Option A is incorrect because a laissez-faire leader does not actively engage the group in planning and decision-making but rather leaves it up to the team members. Option C is incorrect because while a laissez-faire leader may promote independence and creativity, the main characteristic is the passive approach to decision-making. Option D is incorrect because a laissez-faire leader typically provides autonomy and encourages self-motivation among team members. Therefore, the most fitting quality that defines a leader who uses laissez-faire is being passive and delegating decision-making responsibilities to others.
The nurse is assessing a client who presents with progressive proximal to distal muscle weakness and mild diplopia. The nurse realizes these manifestations indicate the client most likely suffers from which peripheral nervous system disease?
A. Systemic lupus erythematosus
B. Speak loudly to help the client interpret what is being said
C. Provide pictures or a communication board to help communicate
D. Gesture the client to the required location or activity
Correct answer:
The correct answer is C: "Provide pictures or a communication board to help communicate." The manifestations of progressive proximal to distal muscle weakness and mild diplopia are characteristic of myasthenia gravis, a chronic autoimmune neuromuscular disease affecting the peripheral nervous system. Myasthenia gravis can cause difficulties with speaking and swallowing due to muscle weakness, making communication challenging for the client. Providing pictures or a communication board can help the client effectively communicate their needs and preferences despite their muscle weakness and diplopia. Systemic lupus erythematosus (option A) is an autoimmune disease that primarily affects multiple organs, not specifically the peripheral nervous system. Options B and D are not relevant to the assessment findings described and do not address the communication challenges associated with myasthenia gravis.
.A client diagnosed with generalized anxiety disorder (GAD) states, \'I just can\'t stop worrying about everything.\' Which nursing diagnosis is most appropriate for this client?
A. Ineffective coping
B. Disturbed thought processes
C. Chronic low self-esteem
D. Social isolation
Correct answer:
The most appropriate nursing diagnosis for a client with generalized anxiety disorder (GAD) who expresses constant worrying would be 'Ineffective coping' (option A). This diagnosis reflects the client's inability to manage stress and anxiety effectively. Clients with GAD often struggle with overwhelming worry and find it challenging to cope with daily stressors. Disturbed thought processes (option B) may involve cognitive impairments or delusions, which do not align with the client's statement. Chronic low self-esteem (option C) pertains to feelings of inadequacy and negative self-perception, which are not directly related to the client's worry about everything. Social isolation (option D) refers to the client's lack of social interactions, which is not the primary concern mentioned in the scenario. Therefore, 'Ineffective coping' is the most suitable nursing diagnosis for this client's situation.
A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn\'s Apgar score.
A. Decrease the rate of infusion of the maintenance IV solution.
B. Discontinue the infusion of the IV oxytocin.
C. Increase the rate of infusion of the IV oxytocin.
D. Slow the client\'s rate of breathing.
Correct answer:
The Apgar score assesses the newborn's overall health and well-being shortly after birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. In this case, the newborn's Apgar score at 1 minute would be 6: 2 points for heart rate (110/min), 1 point for respiratory effort (slow, weak cry), 1 point for muscle tone (some flexion of extremities), 1 point for reflex irritability (grimace in response to suctioning), and 1 point for color (body pink with blue extremities). An Apgar score of 6 at 1 minute indicates that the newborn requires additional support. Discontinuing the infusion of IV oxytocin (choice B) would be the appropriate action to improve the newborn's Apgar score by reducing the potential for respiratory depression or other adverse effects associated with oxytocin administration, which could be contributing to the newborn's low Apgar score.
A nurse is assessing a 4-hour-old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue. What action should the nurse take?
A. Place the naked newborn on the mother\'s bare chest and cover both with a blanket.
B. Apply a warm blanket to the newborn.
C. Monitor the newborn\'s temperature every hour.
D. Perform a blood glucose test on the newborn.
Correct answer:
The correct answer is A: "Place the naked newborn on the mother's bare chest and cover both with a blanket." This action promotes skin-to-skin contact, also known as kangaroo care, which helps regulate the newborn's body temperature and improve bonding between mother and baby. Cool and slightly blue extremities in a newborn can be a sign of decreased body temperature, which can be effectively corrected through skin-to-skin contact. Applying a warm blanket alone may not be as effective as direct skin-to-skin contact. Monitoring the newborn's temperature is important, but the immediate action should be to provide warmth through skin-to-skin contact. Performing a blood glucose test is not indicated based on the presented symptoms of cool and slightly blue extremities. This scenario highlights the importance of kangaroo care in promoting thermoregulation and maternal-infant bonding in newborn care.
A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client\'s oral temperature is 38.9C/102F. Besides notifying the provider, which of the following is the appropriate nursing action?
A. Recheck the client\'s temperature in 4 hr.
B. Administer glucocorticoids intramuscularly.
C. Assess the odor of the amniotic fluid.
D. Prepare the client for emergency cesarean section.
Correct answer:
The correct answer is C: "Assess the odor of the amniotic fluid." When the amniotic membranes rupture, it exposes the fetus to the vaginal environment, increasing the risk of infection. A foul odor may indicate infection, such as chorioamnionitis, which can lead to serious complications for both the mother and the fetus. Assessing the odor of the amniotic fluid is crucial in determining if an infection is present and requires immediate intervention. Rechecking the temperature in 4 hours (A) is not appropriate when there are signs of infection. Administering glucocorticoids (B) is indicated for fetal lung maturity, not for assessing infection. A temperature of 38.9C/102F in a woman in labor with ruptured membranes may indicate infection, but immediate preparation for an emergency cesarean section (D) is not the first step; assessing for signs of infection and notifying the provider is essential.
.A mental health technician asks the nurse, \'How do psychiatrists determine which diagnosis to give a patient?\' Which of these responses by the nurse would be most accurate?
A. Psychiatrists use pre-established criteria from the APAs Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
B. Hospital policy dictates how psychiatrists diagnose mental disorders.
C. Psychiatrists assess the patient and identify diagnoses based on the patient\'s unhealthy responses and contributing factors.
D. The American Medical Association identifies 10 diagnostic labels that psychiatrists can choose from.
Correct answer:
The correct answer is A: "Psychiatrists use pre-established criteria from the APAs Diagnostic and Statistical Manual of Mental Disorders (DSM-5)." The DSM-5 is a widely recognized and accepted tool in the field of psychiatry for diagnosing mental health disorders. It provides specific criteria and guidelines for each disorder, helping psychiatrists accurately identify and classify patients' symptoms. Hospital policy (option B) may influence the diagnostic process to a certain extent but is not the primary source of diagnostic criteria. Option C is vague and does not acknowledge the standardized approach offered by the DSM-5. Option D is incorrect; the American Medical Association does not dictate diagnostic labels for mental health disorders. Understanding and utilizing the DSM-5 criteria is essential for psychiatrists to make accurate diagnoses and provide appropriate treatment for patients.
.A client with obsessive-compulsive disorder (OCD) spends hours each day washing her hands. Which intervention should the nurse implement to help the client reduce this behavior?
A. Encourage the client to set a time limit for washing hands.
B. Encourage the client to wash hands only when necessary.
C. Encourage the client to use hand sanitizer instead of washing.
D. Encourage the client to explore the reasons behind the hand washing.
Correct answer:
The correct answer is A: 'Encourage the client to set a time limit for washing hands.' This intervention is a form of behavioral therapy known as exposure and response prevention (ERP), which is commonly used in treating OCD. Setting a time limit helps the client gradually reduce the excessive hand-washing behavior by creating boundaries and challenging the need for prolonged washing. It allows the client to confront their anxiety and practice delaying or resisting the urge to wash excessively. Encouraging the client to wash hands only when necessary (option B) may not address the underlying compulsions driving the behavior. Using hand sanitizer (option C) does not address the core issue of obsessive hand-washing. Exploring the reasons behind the hand-washing (option D) is important but may not directly help in reducing the behavior without a structured approach like setting time limits.
.A nurse is caring for a client who has been diagnosed with illness anxiety disorder. Which of the following behaviors should the nurse expect?
A. Preoccupation with having a serious illness
B. Fear of social situations
C. Dramatic expressions of emotion
D. Preoccupation with a perceived physical defect
Correct answer:
The correct answer is A: 'Preoccupation with having a serious illness.' Illness anxiety disorder, formerly known as hypochondriasis, is characterized by excessive worry and fear about having a serious medical condition, despite having little or no symptoms. Individuals with this disorder often interpret normal bodily sensations as signs of a severe illness, leading to persistent anxiety and preoccupation with their health. Options B, C, and D are not indicative of illness anxiety disorder. Fear of social situations (B) may be seen in social anxiety disorder, dramatic expressions of emotion (C) could be observed in histrionic personality disorder, and preoccupation with a perceived physical defect (D) is a characteristic of body dysmorphic disorder. Therefore, the most appropriate behavior to expect in a client with illness anxiety disorder is preoccupation with having a serious illness.
A 78-year-old woman is admitted with sudden onset of confusion and disorientation during the early evenings. Her family indicates that she is generally alert and oriented during the day. The nurse would likely recommend:
A. keeping soft lighting without shadows on during the evening.
B. promoting activity and physical exercise during the day.
C. encouraging napping during the day.
D. medicating with sleeping pills.
Correct answer:
The correct answer is A: 'keeping soft lighting without shadows on during the evening.' The sudden onset of confusion and disorientation in the early evenings could be indicative of sundowning, a common phenomenon in older adults with cognitive impairment. Keeping soft lighting without shadows on during the evening can help reduce the symptoms of sundowning by minimizing confusion and disorientation. Promoting activity and physical exercise during the day, as in option B, may also be beneficial but does not directly address the evening symptoms. Encouraging napping during the day, as in option C, may worsen sundowning symptoms by disrupting the sleep-wake cycle. Medicating with sleeping pills, as in option D, should be avoided as it can increase confusion and falls in older adults. Therefore, the nurse would likely recommend option A to help manage the patient's symptoms effectively.
RN exams clinical judgment practice questions, set 115 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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