RN exams clinical judgment practice questions, set 173
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 173
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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 practitioner conducting a neurological assessment on a patient uses a sterile cotton wisp to lightly touch the patient’s forehead, cheek, and chin. The nurse practitioner is testing the:
A. Cranial nerve V (trigeminal)
B. Cranial nerve VII (facial)
C. Cranial nerve XII (hypoglossal)
D. Cranial nerve II (optic)
Show answer and rationale
Correct answer: A — Cranial nerve V (trigeminal)
The correct answer is A: Cranial nerve V (trigeminal). The nurse practitioner is testing the trigeminal nerve's sensory function by using a sterile cotton wisp to assess light touch sensation in the patient's forehead, cheek, and chin. The trigeminal nerve has three branches - ophthalmic, maxillary, and mandibular - which innervate these areas respectively. By assessing the patient's response to the light touch in these specific areas, the nurse practitioner can determine if the sensory function of the trigeminal nerve is intact.
Summary:
B: Cranial nerve VII (facial) controls facial expression, not sensation.
C: Cranial nerve XII (hypoglossal) controls tongue movement, not facial sensation.
D: Cranial nerve II (optic) is responsible for vision, not facial sensation.
Question 2
An adult female patient presents with new-onset diplopia (double vision), altered balance, numbness on one side of the face, and urinary and bowel incontinence. Which finding is consistent with the suspected diagnosis?
A. Lhermitte sign
B. Stereognosis
C. Gel phenomenon
D. Kernig sign
Show answer and rationale
Correct answer: A — Lhermitte sign
The correct answer is A: Lhermitte sign. Lhermitte sign is characterized by an electric shock-like sensation that radiates down the spine and limbs upon neck flexion, indicating a lesion in the cervical spinal cord. In this case, the patient's symptoms of diplopia, altered balance, facial numbness, and incontinence suggest a neurological issue, possibly multiple sclerosis (MS), which commonly presents with Lhermitte sign.
Choice B: Stereognosis involves the ability to recognize objects by touch, not relevant to the patient's symptoms. Choice C: Gel phenomenon is unrelated to the neurological symptoms described. Choice D: Kernig sign is typically associated with meningitis, which does not align with the patient's presentation of neurological deficits suggestive of MS.
Question 3
What is the term for a reflex that does not include a CNS component?
A. long reflex
B. visceral reflex
C. somatic reflex
D. short reflex
Show answer and rationale
Correct answer: D — short reflex
The correct answer is D: short reflex. Short reflexes are reflex actions that do not involve the central nervous system (CNS) and occur entirely at the level of the peripheral nervous system (PNS). These reflexes are mediated by local circuits within the enteric nervous system in the gastrointestinal tract, allowing for rapid responses to stimuli without needing to involve the brain or spinal cord.
A: long reflex - This term refers to reflexes that involve the CNS and typically have a more complex pathway than short reflexes.
B: visceral reflex - This term describes reflexes involving internal organs and can involve both the CNS and PNS components.
C: somatic reflex - This term refers to reflexes involving skeletal muscles and is generally mediated by the CNS.
Question 4
What is the term for a reflex that does not include a CNS component?
A. long reflex
B. visceral reflex
C. somatic reflex
D. short reflex
Show answer and rationale
Correct answer: D — short reflex
The correct answer is D: short reflex. Short reflexes are reflex actions that do not involve the central nervous system (CNS) and occur entirely at the level of the peripheral nervous system (PNS). These reflexes are mediated by local circuits within the enteric nervous system in the gastrointestinal tract, allowing for rapid responses to stimuli without needing to involve the brain or spinal cord.
A: long reflex - This term refers to reflexes that involve the CNS and typically have a more complex pathway than short reflexes.
B: visceral reflex - This term describes reflexes involving internal organs and can involve both the CNS and PNS components.
C: somatic reflex - This term refers to reflexes involving skeletal muscles and is generally mediated by the CNS.
Question 5
A patient delivered vaginally 20 minutes ago. Prophylactic Pitocin is infusing intravenously. During the initial postpartum assessment, the nurse notes a heavy amount of bleeding on the perineal pad. What are the priority nursing actions?
A. Assess the perineum for lacerations and provide a clean peri-pad and ice pack.
B. Assess the fundus and massage the uterus to determine uterine tone and location.
C. Assess to see if the bladder is full and place an indwelling urinary catheter.
D. Assess for clots, determine if this is a normal amount, and provide privacy during a pad change.
Show answer and rationale
Correct answer: B — Assess the fundus and massage the uterus to determine uterine tone and location.
The correct answer is B. Assess the fundus and massage the uterus to determine uterine tone and location. This is the priority action because heavy bleeding postpartum could indicate uterine atony, a common cause of postpartum hemorrhage. By assessing the fundus and massaging the uterus, the nurse can determine if the uterus is firm and well contracted, which helps to control bleeding. Other choices are incorrect as they do not address the immediate concern of uterine atony. Choice A focuses on the perineum and does not address the potential cause of bleeding. Choice C addresses bladder fullness, which is important but not as urgent as assessing for uterine atony. Choice D focuses on clots and privacy but does not address the primary concern of uterine tone.
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Question 6
A patient delivered vaginally 20 minutes ago. Prophylactic Pitocin is infusing intravenously. During the initial postpartum assessment, the nurse notes a heavy amount of bleeding on the perineal pad. What are the priority nursing actions?
A. Assess the perineum for lacerations and provide a clean peri-pad and ice pack.
B. Assess the fundus and massage the uterus to determine uterine tone and location.
C. Assess to see if the bladder is full and place an indwelling urinary catheter.
D. Assess for clots, determine if this is a normal amount, and provide privacy during a pad change.
Correct answer:
The correct answer is B. Assess the fundus and massage the uterus to determine uterine tone and location. This is the priority action because heavy bleeding postpartum could indicate uterine atony, a common cause of postpartum hemorrhage. By assessing the fundus and massaging the uterus, the nurse can determine if the uterus is firm and well contracted, which helps to control bleeding. Other choices are incorrect as they do not address the immediate concern of uterine atony. Choice A focuses on the perineum and does not address the potential cause of bleeding. Choice C addresses bladder fullness, which is important but not as urgent as assessing for uterine atony. Choice D focuses on clots and privacy but does not address the primary concern of uterine tone.
The nurse is observing a new mother interact with her baby and notices the mother holding the baby close to her body. However, the nurse also notices that the mother does not hold the baby in an enface position. Which question is most appropriate for the nurse to ask?
A. Can I help you with a nice position in which to hold your baby?'
B. What can you tell me about your family's beliefs with new babies?'
C. Is there some reason that I have not seen you look into your baby's eyes?'
D. Your baby is so expressive, have you looked into his eyes yet?'
Correct answer:
The correct answer is B: "What can you tell me about your family's beliefs with new babies?". This question is most appropriate as it opens up a dialogue about the mother's cultural or familial practices regarding infant care, which may explain why she is not holding the baby in an enface position. By asking about the family's beliefs, the nurse can gain insight into the mother's perspective and provide culturally sensitive care.
Choice A is incorrect as it assumes the mother needs help without considering her cultural background. Choice C is incorrect as it may come off as judgmental and accusatory. Choice D is incorrect as it focuses on the action of looking into the baby's eyes rather than understanding the cultural context behind the mother's behavior.
The nurse is preparing to do a morning assessment on a 24-hour postpartum patient. Which nursing intervention is most appropriate initially?
A. Massage the fundus until it is firm.
B. Instruct the mother to void prior to the assessment.
C. Assess the lochia flow while massaging the fundus.
D. Lower the head of the bed and have the mother lie flat.
Correct answer:
The correct initial nursing intervention is to instruct the mother to void prior to the assessment (choice B). This is important as a full bladder can interfere with the accuracy of the fundal assessment. By ensuring the mother voids first, the nurse can accurately assess the fundus for any signs of excessive bleeding or abnormalities. This step is crucial in monitoring the postpartum patient's well-being.
Choice A is incorrect as massaging the fundus should come after assessing the lochia flow to prevent potential complications. Choice C is also incorrect as assessing the lochia flow should occur before massaging the fundus. Choice D is incorrect as lowering the head of the bed and having the mother lie flat is not necessary for a postpartum assessment.
Which instruction given to a patient taking a β-blocker is essential to reduce the chance of an adverse response to the β-blocker, regardless of the purpose for which it’s been prescribed?
A. Don’t stop taking this medication without a doctor’s advice first. A severe reaction can happen within days if you stop abruptly.
B. Don’t go too far away from a bathroom; this drug usually causes urinary frequency.
C. It’s likely to cause blurred vision for a few days; you may have trouble reading.
D. It’s likely to cause constipation, so eat plenty of fiber and drink plenty of water.
Correct answer:
The correct answer is A: "Don't stop taking this medication without a doctor's advice first." Abruptly stopping a β-blocker can lead to severe adverse reactions like rebound hypertension, angina exacerbation, or arrhythmias due to sudden withdrawal. This instruction is crucial to prevent these potentially dangerous consequences.
Explanation for why other choices are incorrect:
B: β-blockers are not known to commonly cause urinary frequency, so this warning is unnecessary.
C: Blurred vision is not a common side effect of β-blockers, so this warning is irrelevant.
D: While constipation can be a side effect of some medications, it is not a prominent side effect of β-blockers, so this advice is not essential for patients taking β-blockers.
Which woman is the best candidate for a trial of labor after cesarean (TOLAC)?
A. A 34-year-old gravida 2, para 1 with one previous classical cesarean section for prematurity
B. A 21-year-old gravida 2, para 1 with one previous low-transverse cesarean section for CPD
C. A 31-year-old gravida 4, para 2 with one previous low-transverse cesarean section for late decelerations
D. A 27-year-old gravida 3, para 2 with one previous T-shaped incision for macrosomia
Correct answer:
The correct answer is B: A 21-year-old gravida 2, para 1 with one previous low-transverse cesarean section for CPD. This candidate is the best choice for a trial of labor after cesarean (TOLAC) because a low-transverse incision has the lowest risk of uterine rupture during labor compared to classical, T-shaped, or vertical incisions. Additionally, the indication for the previous cesarean section being cephalopelvic disproportion (CPD) suggests that the pelvis may have been the limiting factor in the previous delivery, making a TOLAC a reasonable option. The other choices have higher risks of uterine rupture (classical incision, T-shaped incision) or indications that may increase the likelihood of complications during TOLAC (prematurity, late decelerations).
Which woman is the best candidate for a trial of labor after cesarean (TOLAC)?
A. A 34-year-old gravida 2, para 1 with one previous classical cesarean section for prematurity
B. A 21-year-old gravida 2, para 1 with one previous low-transverse cesarean section for CPD
C. A 31-year-old gravida 4, para 2 with one previous low-transverse cesarean section for late decelerations
D. A 27-year-old gravida 3, para 2 with one previous T-shaped incision for macrosomia
Correct answer:
The correct answer is B: A 21-year-old gravida 2, para 1 with one previous low-transverse cesarean section for CPD. This candidate is the best choice for a trial of labor after cesarean (TOLAC) because a low-transverse incision has the lowest risk of uterine rupture during labor compared to classical, T-shaped, or vertical incisions. Additionally, the indication for the previous cesarean section being cephalopelvic disproportion (CPD) suggests that the pelvis may have been the limiting factor in the previous delivery, making a TOLAC a reasonable option. The other choices have higher risks of uterine rupture (classical incision, T-shaped incision) or indications that may increase the likelihood of complications during TOLAC (prematurity, late decelerations).
The nurse is caring for a woman with a history of a previous preterm birth. Based on current knowledge related to cervical incompetency, which should the nurse do?
A. Prepare the woman for an abdominal ultrasound
B. Place the patient on her left side to increase perfusion to the fetus
C. Be prepared to discuss the action and side effects of progesterone
D. Monitor the patient’s blood pressure closely
Correct answer:
The correct answer is C because progesterone is recommended for women with a history of preterm birth due to cervical incompetency. Progesterone helps to reduce the risk of another preterm birth by supporting the cervix and preventing it from opening too early. It is important for the nurse to discuss the action and side effects of progesterone with the patient to ensure informed decision-making.
Choice A is incorrect as an abdominal ultrasound is not directly related to managing cervical incompetency. Choice B is incorrect as positioning the patient on her left side does not address the issue of cervical incompetency. Choice D is also incorrect as monitoring blood pressure is not the primary intervention for managing cervical incompetency in this case.
Which of the following drugs is associated with the reaction of hepatitis?
A. Valproic acid
B. Quinidine
C. Isoniazid
D. Ethosuximide
Correct answer:
The correct answer is C: Isoniazid. Isoniazid is a medication commonly used to treat tuberculosis, but it is also known to be associated with causing hepatitis. Hepatitis is an inflammatory condition of the liver that can be caused by various factors, including medications. Valproic acid is more commonly associated with hepatotoxicity in the form of liver failure rather than hepatitis. Quinidine is known to cause a different type of liver injury called drug-induced immune-mediated liver injury. Ethosuximide is primarily used to treat absence seizures and is not typically associated with causing hepatitis. Therefore, among the options provided, isoniazid is the drug most closely associated with the reaction of hepatitis.
Which of the following drugs is associated with the reaction of Tendon dysfunction?
A. Digitalis
B. Niacin
C. Tetracycline
D. Fluoroquinolones
Correct answer:
The correct answer is D: Fluoroquinolones. Fluoroquinolones are a class of antibiotics known to be associated with the side effect of tendon dysfunction, such as tendon rupture or tendinitis. This adverse reaction occurs because fluoroquinolones can disrupt the structure and function of tendons, leading to increased risk of tendon injuries. Digitalis (A) is a medication used in the treatment of heart conditions, niacin (B) is a B vitamin used to lower cholesterol levels, and tetracycline (C) is an antibiotic but not typically associated with tendon dysfunction. Therefore, the correct choice in this question is fluoroquinolones (D) due to their known association with tendon issues.
Which of the following drugs is associated with the reaction of Stevens-Johnson syndrome?
A. Valproic acid
B. Quinidine
C. Isoniazid
D. Ethosuximide
Correct answer:
Stevens-Johnson syndrome is a severe skin reaction that can be triggered by certain medications. Isoniazid, the correct answer choice (C), is a well-known drug associated with Stevens-Johnson syndrome. It is important for students to recognize this association as Stevens-Johnson syndrome is a potentially life-threatening condition characterized by skin rash, blisters, and mucous membrane involvement. Valproic acid (A) is more commonly linked to other adverse effects like hepatotoxicity, while Quinidine (B) is known for causing QT prolongation and Ethosuximide (D) is used to treat absence seizures without a significant association with Stevens-Johnson syndrome.
RN exams clinical judgment practice questions, set 173 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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