RN exams clinical judgment practice questions, set 172
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 172
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 RN exams exam guide or more RN exams 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
Who is best equipped to help a nursing assistant communicate with a resident who speaks a different language than the nursing assistant does?
A. A language arts teacher
B. An interpreter
C. A spiritual advisor
D. The nursing assistant's close friend
Show answer and rationale
Correct answer: B — An interpreter
The correct answer is B: An interpreter. An interpreter is specifically trained to facilitate communication between individuals who speak different languages. They have the necessary language skills and cultural understanding to accurately convey messages between the nursing assistant and the resident. A language arts teacher may not have the same level of proficiency in the resident's language, and their role is focused on teaching language skills rather than interpreting. A spiritual advisor may not have the language skills required for effective communication in this context. The nursing assistant's close friend is not a professional interpreter and may not have the necessary language proficiency or objectivity to effectively bridge the communication gap.
Question 2
A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, 'I quit smoking after my wife died 7 years ago.' However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
A. Mr. K., I know that you are lying.'
B. Mr. K., come on, tell me how much you smoke.'
C. Mr. K., I didn't realize your wife had died. It must be difficult for you at this time. Please tell me more about that.'
D. Mr. K., you have said that you don't smoke, but I see that you have an open pack of cigarettes in your pocket.'
Show answer and rationale
Correct answer: D — Mr. K., you have said that you don't smoke, but I see that you have an open pack of cigarettes in your pocket.'
The correct answer is D because it directly addresses the discrepancy between the patient's statement and the observation made by the nurse. By using confrontation in a non-judgmental manner, the nurse can bring attention to the inconsistency and encourage Mr. K. to clarify his tobacco use accurately. This approach promotes honesty and trust between the nurse and the patient.
Choice A is incorrect because it is accusatory and may lead to defensiveness from the patient. Choice B is also incorrect as it does not address the observed behavior and may not effectively resolve the discrepancy. Choice C is invalid as it shifts the focus away from the issue of tobacco use and towards the patient's personal life, which is not the primary concern in this scenario.
Question 3
What is the best indicator of a successful transition to hospice care for older adults?
A. Complete cessation of all medical treatments
B. Improvement in physical strength
C. Relief from physical, emotional, and spiritual suffering
D. Long-term emotional stability
Show answer and rationale
Correct answer: C — Relief from physical, emotional, and spiritual suffering
The correct answer is C: Relief from physical, emotional, and spiritual suffering. This is the best indicator of a successful transition to hospice care for older adults because hospice care focuses on providing comfort and improving quality of life rather than curative treatments. Relief from suffering aligns with the goals of hospice care, addressing the holistic needs of patients. Choice A is incorrect as complete cessation of all medical treatments may not be appropriate for all patients in hospice care. Choice B is incorrect as improvement in physical strength may not be the primary goal in hospice care. Choice D is incorrect as long-term emotional stability is important but not necessarily the best indicator of a successful transition to hospice care.
Question 4
Which behavior would the nurse expect to observe in a person who commits psychic rape?
A. The perpetrator gives money to the patient after the rape.
B. The perpetrator seduces the patient by providing wine, flowers, and music.
C. The perpetrator threatens the patient to submit or else be severely beaten.
D. The perpetrator mentions always including violent bondage in sexual activities.
Show answer and rationale
Correct answer: D — The perpetrator mentions always including violent bondage in sexual activities.
The correct answer is D because mentioning violent bondage in sexual activities indicates a pattern of behavior associated with psychic rape, where the perpetrator exerts control and inflicts harm on the victim. This choice aligns with the power dynamics and manipulation typically seen in cases of psychic rape.
A: Giving money after the rape does not necessarily indicate psychic rape and is more characteristic of bribery or transactional behavior.
B: Seduction with wine, flowers, and music may indicate manipulation but does not specifically relate to the psychological violation inherent in psychic rape.
C: Threatening the patient with violence is a form of physical coercion rather than psychic rape, which involves psychological manipulation and violation.
Question 5
An 18-year-old referred to the mental health center often cooks gourmet meals but eats only tiny portions. The patient wears layers of loose clothing saying, "I like the style." The patient's weight dropped from 130 to 95 pounds. She has amenorrhea. Which diagnosis is most likely?
A. Eating disorder not otherwise specified
B. Anorexia nervosa
C. Bulimia nervosa
D. Binge eating
Show answer and rationale
Correct answer: B — Anorexia nervosa
The correct diagnosis is B: Anorexia nervosa. This patient exhibits key symptoms such as restrictive eating leading to significant weight loss, wearing layers of clothing to hide body shape, and amenorrhea. These symptoms align with the diagnostic criteria for anorexia nervosa. The other choices are incorrect because they do not fully capture the combination of symptoms present in this case. Choice A (Eating disorder not otherwise specified) is too broad and does not specify the severity of the symptoms. Choice C (Bulimia nervosa) typically involves binge eating followed by compensatory behaviors, which is not indicated in this case. Choice D (Binge eating) focuses solely on overeating without the restrictive eating and weight loss seen in anorexia nervosa.
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Question 6
An 18-year-old referred to the mental health center often cooks gourmet meals but eats only tiny portions. The patient wears layers of loose clothing saying, "I like the style." The patient's weight dropped from 130 to 95 pounds. She has amenorrhea. Which diagnosis is most likely?
A. Eating disorder not otherwise specified
B. Anorexia nervosa
C. Bulimia nervosa
D. Binge eating
Correct answer:
The correct diagnosis is B: Anorexia nervosa. This patient exhibits key symptoms such as restrictive eating leading to significant weight loss, wearing layers of clothing to hide body shape, and amenorrhea. These symptoms align with the diagnostic criteria for anorexia nervosa. The other choices are incorrect because they do not fully capture the combination of symptoms present in this case. Choice A (Eating disorder not otherwise specified) is too broad and does not specify the severity of the symptoms. Choice C (Bulimia nervosa) typically involves binge eating followed by compensatory behaviors, which is not indicated in this case. Choice D (Binge eating) focuses solely on overeating without the restrictive eating and weight loss seen in anorexia nervosa.
A victim of a violent rape was treated in the emergency department. As discharge preparation begins, the victim says softly, "I will never be the same again. I can't face my friends. There is no reason to go on."Â Select the nurse's most appropriate response.
A. Are you thinking of harming yourself?
B. It will take time, but you will feel the same.
C. Your friends will understand when you explain it was not your fault.
D. You will be able to find meaning in this experience as time goes on.
Correct answer:
The correct answer is A: "Are you thinking of harming yourself?" This response is the most appropriate because the victim is expressing hopelessness and suicidal ideation, which indicates a need for immediate intervention and assessment for safety. By asking directly about self-harm, the nurse can assess the severity of the situation and take appropriate actions to ensure the victim's safety.
Summary of other choices:
B: This response minimizes the victim's feelings and does not address the seriousness of the situation.
C: This response ignores the victim's emotional distress and does not address the potential for self-harm.
D: This response dismisses the victim's current feelings and does not provide immediate support for the expressed hopelessness.
Which information will the nurse include in the teaching plan for a patient newly diagnosed with asthma?
A. Use the inhaled corticosteroid when shortness of breath occurs.
B. Inhale slowly and deeply when using the dry powder inhaler (DPI).
C. Hold your breath for 5 seconds after using the bronchodilator inhaler.
D. Tremors are an expected side effect of rapidly acting bronchodilators.
Correct answer:
Step 1: Tremors as a side effect of rapidly acting bronchodilators are common due to their impact on the sympathetic nervous system.
Step 2: Educating the patient about this side effect prepares them for what to expect and reduces anxiety.
Step 3: This knowledge helps the patient differentiate between expected side effects and potential adverse reactions.
Step 4: It is crucial for the patient to be informed about common side effects to ensure adherence to treatment.
Summary:
Choice D is correct because informing the patient about expected side effects like tremors is essential for treatment adherence. Choices A, B, and C are incorrect because they do not address crucial information related to side effects and proper inhaler technique for asthma management.
A patient recovering from a stroke demonstrates neglect on the left side. Which intervention is MOST appropriate to address this deficit?
A. Position objects on the unaffected side
B. Encourage scanning to the left side
C. Provide verbal cues to the right side
D. Focus therapy on the unaffected side
Correct answer:
The correct answer is B: Encourage scanning to the left side. This intervention is appropriate because it helps the patient actively engage in exploring their neglected side, promoting awareness and attention to that side. By encouraging scanning to the left, the patient can improve their ability to attend to and interact with stimuli on the neglected side.
A: Position objects on the unaffected side does not actively engage the patient in addressing the neglect on the left side.
C: Providing verbal cues to the right side may not effectively stimulate the neglected side and may not promote active engagement.
D: Focusing therapy on the unaffected side does not directly address the neglect on the left side and may not lead to improvement in neglect symptoms.
The nurse is planning care for a client with type I insulin dependent diabetes mellitus (IDDM). Which statement best reflects a short-term goals for this client?
A. Risk for ineffective coping related to anxiety about medical diagnosis
B. The client will understand how to prevent the development of complications
C. The nurse will teach the client to recognize the signs and symptoms of hypoglycemia and hyperglycemia today
D. The client will identify elements of the basic diabetic diet by the end of the week
Correct answer:
The correct answer is D because identifying elements of the basic diabetic diet is a short-term goal that is specific, measurable, achievable, relevant, and time-bound (SMART). This goal directly addresses the immediate need to manage blood glucose levels through proper nutrition. By the end of the week, the client should be able to apply this knowledge to their daily routine.
A: While coping with anxiety is important, it is not directly related to the short-term management of diabetes.
B: Understanding how to prevent complications is essential but may be a more long-term goal.
C: Teaching about signs and symptoms of hypoglycemia and hyperglycemia is crucial, but it is more of an immediate educational need rather than a goal for the client to achieve.
You are reviewing assessment data of a 45-year-old male patient who had recent surgery and rates his pain at 8 on a 10-point scale. As you review the electronic health record, you note which of the following cues related to the patient's pain? Select all that apply.
A. Normal skin turgor
B. Normal S1, S2 heart sounds
C. Glowing skin
D. Tachypnea (rapid breathing)
Correct answer:
The correct answer is D: Tachypnea (rapid breathing). This is a cue related to the patient's pain because pain can lead to increased respiratory rate as a physiological response. The body's natural reaction to pain is to increase breathing to provide more oxygen to tissues. Therefore, tachypnea is a relevant cue to assess pain levels.
A: Normal skin turgor is not directly related to pain assessment. Skin turgor is typically assessed to evaluate hydration status.
B: Normal S1, S2 heart sounds are not directly related to pain assessment. Heart sounds are assessed to evaluate cardiac function.
C: Glowing skin is not a typical cue related to pain assessment. Glowing skin may be associated with overall health and well-being but is not directly related to pain.
Pituitary Gland, Which is Also the Master Endocrine Gland Is Controlled by Which of the Following?
A. Thyroid
B. Hypothalamus
C. Pineal gland
D. None of the above
Correct answer:
The correct answer is B: Hypothalamus. The hypothalamus controls the pituitary gland by releasing hormones that stimulate or inhibit pituitary hormone production. This relationship is known as the hypothalamic-pituitary axis. The hypothalamus is considered the master controller of the endocrine system, making it the correct choice.
A: Thyroid - The thyroid gland is not directly responsible for controlling the pituitary gland. It is a separate endocrine gland that produces its own hormones.
C: Pineal gland - The pineal gland primarily regulates the sleep-wake cycle and produces melatonin. It does not play a direct role in controlling the pituitary gland.
D: None of the above - This is incorrect as the hypothalamus does indeed control the pituitary gland.
An 18-year-old referred to the mental health center often cooks gourmet meals but eats only tiny portions. The patient wears layers of loose clothing saying, "I like the style."Â The patient's weight dropped from 130 to 95 pounds. She has amenorrhea. Which diagnosis is most likely?
A. Eating disorder not otherwise specified
B. Anorexia nervosa
C. Bulimia nervosa
D. Binge eating
Correct answer:
The correct answer is B: Anorexia nervosa. This diagnosis fits the patient's symptoms of restrictive eating, significant weight loss, amenorrhea, and denial of the severity of the situation. The patient's behavior of cooking gourmet meals but eating tiny portions and wearing layers of clothes to hide weight loss are classic signs of anorexia nervosa. The other choices are incorrect because:
A: Eating disorder not otherwise specified does not fully capture the severity and specific symptoms exhibited by the patient.
C: Bulimia nervosa involves binge-eating followed by compensatory behaviors, which are not described in the scenario.
D: Binge eating disorder involves recurrent episodes of binge eating without compensatory behaviors, which is not indicated.
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?
A. Sternal rub.
B. Nail bed pressure.
C. Pressure on the orbital rim.
D. Squeezing of the sternocleidomastoid muscle.
Correct answer:
The correct answer is B: Nail bed pressure. This is the appropriate method to test the client's peripheral response to pain in an unconscious state. Applying pressure to the nail bed can elicit a localized pain response, indicating intact peripheral nerve function.
Rationale:
1. Nail bed pressure is a sensitive area that can evoke a pain response if the client has intact peripheral nerve function.
2. Sternal rub (A) is a sternal pressure technique used to arouse a client, not specifically to test peripheral response.
3. Pressure on the orbital rim (C) is not appropriate for testing peripheral response and can be harmful.
4. Squeezing the sternocleidomastoid muscle (D) is a method to assess cranial nerve XI function, not peripheral response to pain.
A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, 'I quit smoking after my wife died 7 years ago.' However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say:
A. Mr. K., I know that you are lying.'
B. Mr. K., come on, tell me how much you smoke.'
C. Mr. K., I didn't realize your wife had died. It must be difficult for you at this time. Please tell me more about that.'
D. Mr. K., you have said that you don't smoke, but I see that you have an open pack of cigarettes in your pocket.'
Correct answer:
The correct answer is D because it directly addresses the discrepancy between the patient's statement and the observation made by the nurse. By using confrontation in a non-judgmental manner, the nurse can bring attention to the inconsistency and encourage Mr. K. to clarify his tobacco use accurately. This approach promotes honesty and trust between the nurse and the patient.
Choice A is incorrect because it is accusatory and may lead to defensiveness from the patient. Choice B is also incorrect as it does not address the observed behavior and may not effectively resolve the discrepancy. Choice C is invalid as it shifts the focus away from the issue of tobacco use and towards the patient's personal life, which is not the primary concern in this scenario.
RN exams clinical judgment practice questions, set 172 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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