RN exams clinical judgment practice questions, set 165
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 165
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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
The nurse is caring for an immune-compromised patient. The patient displays a low-grade fever and complains of a burning and shooting pain, along with itching and tingling, that progresses from the clavicle to the scapula. The nurse suspects that the patient will undergo evaluation for which infection?
A. Herpes simplex
B. Shingles
C. Cytomegalovirus
D. Epstein-Barr virus
Show answer and rationale
Correct answer: B — Shingles
The patient's symptoms of burning, shooting pain, itching, and tingling that follow a dermatomal pattern from the clavicle to the scapula are indicative of shingles, also known as herpes zoster. Shingles is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox, especially in individuals with weakened immune systems. Herpes simplex typically presents with cold sores or genital lesions. Cytomegalovirus and Epstein-Barr virus are less likely to present with the specific symptoms described in the patient's case. Therefore, the nurse's suspicion of the patient undergoing evaluation for shingles is appropriate in this scenario, making option B the correct answer.
Question 2
Which of the following are sources of clear guidelines for upholding clinical standards for safe and competent care? (Select all that apply.)
A. The state\'s nurse practice act (NPA)
B. The State Board of Nurse Examiners (BNE)
C. The National Association for Practical Nurse Education and Service (NAPNES)
D. Institutional policies
Show answer and rationale
Correct answer: C — The National Association for Practical Nurse Education and Service (NAPNES)
The National Association for Practical Nurse Education and Service (NAPNES) is a reputable organization that provides clear guidelines for upholding clinical standards for safe and competent care. The state's nurse practice act (NPA) and the State Board of Nurse Examiners (BNE) primarily focus on regulatory aspects and licensure requirements, rather than specific clinical standards. Institutional policies may vary in their comprehensiveness and alignment with best practices, making them less reliable sources of clear and standardized guidelines. Therefore, NAPNES is the most appropriate choice as it specifically focuses on practical nurse education and sets standards for safe and competent care.
Question 3
When doing an initial assessment, why should the LPN/LVN be particularly interested in the patient\'s educational background?
A. To determine the patient\'s reading level
B. To help the patient develop a reading plan
C. To understand the patient\'s background
D. To ensure the patient can follow instructions
Show answer and rationale
Correct answer: D — To ensure the patient can follow instructions
The LPN/LVN should be particularly interested in the patient's educational background during an initial assessment to ensure the patient can follow instructions effectively. Understanding the patient's educational background helps the nurse tailor communication and instructions to suit the patient's comprehension level. This is crucial for providing safe and effective care as it ensures that the patient can understand and adhere to the treatment plan, medications, and self-care instructions. By knowing the patient's educational background, the LPN/LVN can make necessary adjustments to promote better health outcomes and prevent misunderstandings or errors in following healthcare recommendations.
Question 4
.A patient presents in the Emergency Department immediately following a shooting incident in a school where she has been teaching. There is no evidence of physical injury, but she appears very hyperactive and talkative. Which of these symptoms manifested by the patient is uncommon initial biological responses to stress?
A. Constricted pupils
B. Watery eyes
C. Palpitations
D. Increased heart rate
Show answer and rationale
Correct answer: A — Constricted pupils
The correct answer is A: Constricted pupils. During a stress response, the body typically undergoes physiological changes to prepare for a 'fight or flight' situation. Symptoms like palpitations, increased heart rate, and watery eyes are common initial biological responses to stress as they are associated with the activation of the sympathetic nervous system. However, constricted pupils are not a typical initial response to stress. In a high-stress situation like a shooting incident, dilated pupils would be expected to allow more light in for heightened awareness, making constricted pupils an uncommon symptom in this context.
Question 5
The nurse is assessing a 13-year-old girl. Which event would the nurse expect to have occurred first?
A. evidence of pubic hair
B. development of breast buds
C. onset of menses
D. growth spurt
Show answer and rationale
Correct answer: B — development of breast buds
The correct answer is B: "development of breast buds." In the normal sequence of puberty for girls, the first sign of physical development is usually the growth of breast buds, also known as thelarche. This typically occurs before the onset of other events such as the appearance of pubic hair, onset of menses, or a growth spurt. Breast development usually begins around age 8-13, followed by the appearance of pubic hair, then menarche (first menstrual period), and finally a growth spurt. Therefore, the nurse would expect to observe breast bud development as the initial event in the progression of puberty in a 13-year-old girl.
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Question 6
A nurse is caring for a client taking oral morphine and docusate sodium. The nurse should instruct the client that taking the docusate sodium daily can minimize which of the following adverse effects of morphine?
A. Explain that docusate sodium may cause dizziness.
B. Advise that morphine may cause respiratory depression.
C. Encourage the client to drink plenty of fluids.
D. Monitor for constipation.
Correct answer:
The correct answer is D. Morphine is an opioid pain medication that commonly causes constipation as a side effect due to its effects on the gastrointestinal system. Docusate sodium is a stool softener that helps prevent or relieve constipation by allowing water and fats to mix with stool, making it easier to pass. By taking docusate sodium daily while on morphine, the client can help prevent constipation, a common adverse effect of morphine. It is important for the nurse to educate the client on the importance of monitoring for constipation and taking measures to prevent it, such as staying hydrated and using stool softeners.
Which of the following are not treated with Hydrochlorothiazide?
A. CHF
B. HTN
C. Nephritis
D. Hypercalciuria
Correct answer:
Hydrochlorothiazide is a diuretic commonly used to treat hypertension (HTN) and congestive heart failure (CHF) by reducing blood pressure and fluid retention. It can also be used to manage hypercalciuria by increasing the excretion of calcium in the urine. However, hydrochlorothiazide is not typically used to treat nephritis, which is an inflammatory condition of the kidneys. Nephritis often requires specific treatments tailored to the underlying cause and may not respond well to diuretics like hydrochlorothiazide. Therefore, option C, 'Nephritis,' is the correct answer as it is not typically treated with Hydrochlorothiazide.
Myasthenia gravis is an autoimmune disease of the neuromuscular junction characterized by the fluctuating weakness of certain skeletal muscle groups. The use of intravenous immune globulin is for which response?
A. Increase anxiety and depression
B. Reduces the production of acetylcholine antibodies
C. Removes the antibodies produced by the autoimmune response
D. Increases the production of acetylcholine antibodies
Correct answer:
Myasthenia gravis is caused by antibodies attacking acetylcholine receptors at the neuromuscular junction, leading to muscle weakness. Intravenous immune globulin (IVIG) contains antibodies that can help remove the harmful antibodies produced by the autoimmune response in myasthenia gravis. This treatment approach aims to reduce the levels of the pathogenic antibodies and alleviate symptoms by blocking their effects on acetylcholine receptors. Therefore, option C, 'Removes the antibodies produced by the autoimmune response,' is the correct response as IVIG helps to neutralize the autoantibodies responsible for the condition.
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client’s BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client’s BP is 176/96 mm Hg. Which of the following actions should the nurse make?
A. Measure the client’s BP in the other arm.
B. Use a narrower cuff to repeat the BP measurement.
C. Deflate the cuff faster when repeating the bp measurement.
D. Request a prescription for an antihypertension medication.
Correct answer:
The correct answer is A: 'Measure the client’s BP in the other arm.' When there is a significant difference in blood pressure readings between the arms, it can indicate arterial blockages or other vascular issues. By measuring the BP in the other arm, the nurse can determine if the high reading is accurate or if there is a discrepancy due to positioning or equipment. Using a narrower cuff (B) or deflating the cuff faster (C) are not appropriate actions in this situation. Requesting antihypertensive medication (D) based on one high reading without further assessment is premature and could lead to unnecessary treatment.
.A school nurse is assessing a female high school student who is overly concerned about her appearance. The client\'s mother states, \'That\'s not something to be stressed about!\' Which is the most appropriate nursing response?
A. Teenagers! They don\'t know a thing about real stress.
B. Stress occurs only when there is a loss.
C. When you are in poor physical condition, you can\'t experience psychological well-being.
D. Stress can be psychological. A threat to self-esteem may result in high stress levels.
Correct answer:
The correct answer is D. Stress can indeed be psychological, and a threat to self-esteem is a common trigger for high stress levels among teenagers. By acknowledging this and providing this information to the student and her mother, the nurse can help them understand the potential sources of stress and work towards addressing them effectively. Option A is dismissive and unprofessional, not acknowledging the client's concerns. Option B is incorrect as stress can be caused by various factors, not just loss. Option C is also incorrect as psychological well-being can be affected by various factors, not solely physical condition.
The nurse is planning a teaching session to adolescents about deaths by unintentional injuries. Which should the nurse include in the session with regard to deaths caused by injuries?
A. More deaths occur in males.
B. More deaths occur in females.
C. The pattern of deaths does not vary according to age and sex.
D. The pattern of deaths does not vary widely among different ethnic groups.
Correct answer:
The correct answer is A: 'More deaths occur in males.' This is an important point to include in the teaching session because statistics show that unintentional injury-related deaths are more common in males compared to females. This information is crucial for adolescents to be aware of to help them understand the risks and take appropriate precautions to prevent injuries. By acknowledging this gender difference, the nurse can tailor the education and prevention strategies to better address the higher risk faced by males in this age group. Understanding this pattern will help adolescents make informed decisions and stay safe.
The nurse is teaching parents about impetigo. Which of the following should the nurse include in the teaching?
A. Impetigo is a bacterial infection that is not contagious.
B. Impetigo can be treated with antifungal medications.
C. Impetigo is highly contagious and spreads easily.
D. Impetigo does not require medical treatment.
Correct answer:
The correct answer is C. Impetigo is a highly contagious bacterial skin infection that spreads easily through direct contact with infected individuals or contaminated objects. It is important for parents to understand the contagious nature of impetigo to prevent its spread within the household or community. Incorrect options A, B, and D provide inaccurate information. Impetigo is caused by bacteria, not fungi, so it is not treated with antifungal medications. Additionally, impetigo typically requires medical treatment, which may include antibiotics or topical medications to help clear the infection and prevent complications.
A client with a head injury presents with signs and symptoms of increased intracranial pressure. Which nursing intervention would help reduce the pressure?
A. Place the neck in a neutral position to promote venous drainage
B. Determine a nursing diagnosis and set priorities for expected goals
C. Assess the patient completely and determine what outcomes are realistic
D. Assess the major problems and begin interventions
Correct answer:
Placing the neck in a neutral position is the correct nursing intervention to help reduce increased intracranial pressure in a client with a head injury. This position promotes venous drainage from the brain, which can help decrease the pressure inside the skull. By keeping the neck in a neutral position, the nurse can facilitate optimal blood flow and reduce the risk of further complications associated with increased intracranial pressure, such as brain herniation. It is essential to prioritize interventions that directly address the physiological issue at hand, making option A the most appropriate choice in this scenario.
.A nurse is caring for a client who has been diagnosed with depersonalization/derealization disorder. Which of the following behaviors should the nurse expect?
A. Feelings of detachment from one\'s body
B. Fear of gaining weight
C. Paralysis of a limb
D. Episodes of hypomania
Correct answer:
The correct answer is A: 'Feelings of detachment from one's body.' Depersonalization/derealization disorder is characterized by feelings of detachment from oneself and surroundings, not just the physical body. Individuals with this disorder may feel like they are observing themselves from outside their bodies or that the world around them is unreal or distorted. The other options, fear of gaining weight, paralysis of a limb, and episodes of hypomania, are not typically associated with depersonalization/derealization disorder. Therefore, the nurse should expect the client to experience feelings of detachment from their body.
Which of the following are not treated with Prednisone?
A. Cushing’s disease
B. Testicular cancer
C. Lympthomas
D. Chronic leukemias
Correct answer:
Prednisone is a corticosteroid commonly used to treat a variety of conditions by suppressing the immune system and reducing inflammation. Cushing's disease, lymphomas, and chronic leukemias are conditions that can be treated with Prednisone due to its anti-inflammatory and immunosuppressive properties. However, testicular cancer is not typically treated with Prednisone as the primary method of treatment. Testicular cancer is usually managed through surgery, chemotherapy, and radiation therapy, depending on the stage and type of cancer. Therefore, option B is the correct answer as it is not commonly treated with Prednisone.
RN exams clinical judgment practice questions, set 165 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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