RN exams clinical judgment practice questions, set 25
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 25
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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
Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife would indicate to a nurse that the client is in the acceptance stage of grief?
A. If only we could have tried again, things might have worked out.
B. I am so mad that the children and I had to put up with him as long as we did.
C. Yes, it was a difficult relationship, but I think I have learned from the experience.
D. I have a difficult time getting out of bed most days.
Show answer and rationale
Correct answer: C — Yes, it was a difficult relationship, but I think I have learned from the experience.
The correct answer is C: "Yes, it was a difficult relationship, but I think I have learned from the experience." This statement indicates acceptance because the wife acknowledges the difficulty of the relationship but also expresses personal growth and learning from it. Acceptance stage involves coming to terms with the reality of the situation and finding meaning or lessons in the experience.
A: "If only we could have tried again, things might have worked out." - This statement suggests bargaining, which is a stage before acceptance where the individual is trying to negotiate or change the outcome.
B: "I am so mad that the children and I had to put up with him as long as we did." - This statement reflects anger, another stage of grief where the individual may feel resentful or frustrated about the situation.
D: "I have a difficult time getting out of bed most days." - This statement indicates symptoms of depression or denial, which are common in earlier stages of grief, not acceptance.
Question 2
A patient states, "I feel so sad all of the time. I can't feel happy even doing things I used to enjoy doing.' He also says that he is tired, sleeps poorly, and has no energy. To differentiate between dysthymic disorder and a major depressive disorder, which of the following questions should the nurse ask him?
A. Has there been any change in your weight?
B. Are you having any thoughts of suicide?
C. How long have you been feeling this way?
D. Are you having feelings of worthlessness?
Show answer and rationale
Correct answer: C — How long have you been feeling this way?
Rationale: The correct answer is C: "How long have you been feeling this way?" This question is essential to differentiate between dysthymic disorder and major depressive disorder. In dysthymic disorder, symptoms persist for at least 2 years, whereas in major depressive disorder, symptoms typically last for at least 2 weeks. By asking how long the patient has been feeling this way, the nurse can determine the duration of the symptoms and make a more accurate diagnosis.
Summary of other choices:
A: "Has there been any change in your weight?" This question is more relevant to assessing changes in appetite, which can be a symptom of depression, but it does not differentiate between dysthymic and major depressive disorders.
B: "Are you having any thoughts of suicide?" While important to assess for safety, this question does not help differentiate between the two disorders.
D: "Are you having feelings of worthlessness?" This question is relevant to assessing symptoms of depression but does not
Question 3
A 30 year old male presents with a stab wound to the abdomen. BP is 85/60, HR 130, RR 26 and GCS 14. Neck veins are flat and chest examination is clear with bilateral breath sounds. Optimal resuscitation should include:
A. "Transfusion of FFP and platelets"
B. "Preparation for laparotomy while initiating fluid resuscitation"
C. "Resuscitation with crystalloid and pRBC until base excess is normal"
D. "Fluid resuscitation and angioembolization"
Show answer and rationale
Correct answer: B — "Preparation for laparotomy while initiating fluid resuscitation"
The correct answer is B: "Preparation for laparotomy while initiating fluid resuscitation." In this scenario, the patient is hemodynamically unstable with signs of hypovolemic shock. The priority is to address the source of bleeding, which is likely intra-abdominal due to the stab wound. Therefore, preparing for a laparotomy to control the bleeding is crucial. Fluid resuscitation should be initiated to stabilize the patient's hemodynamics and improve tissue perfusion. This approach addresses the immediate life-threatening issue and is the most appropriate course of action to prevent further deterioration.
Explanation for other choices:
A: "Transfusion of FFP and platelets" - This option does not address the immediate need for controlling bleeding and stabilizing the patient's hemodynamics.
C: "Resuscitation with crystalloid and pRBC until base excess is normal" - While fluid resuscitation is necessary, waiting for base excess to normalize may delay definitive treatment and compromise the
Question 4
Which is the preferred mode of transmission of HIV from a mother to a child?
A. during delivery through mixing of blood
B. during pregnancy through placenta
C. via breastmilk during lactation
D. All of the above
Show answer and rationale
Correct answer: D — All of the above
The correct answer is D: All of the above. HIV can be transmitted from mother to child during delivery through mixing of blood, during pregnancy through the placenta, and via breastmilk during lactation. Each mode of transmission carries a risk of HIV transmission to the child due to the presence of the virus in the mother's blood and bodily fluids. It is important to note that all three modes contribute to the risk of mother-to-child transmission of HIV, and preventive measures should be taken to reduce this risk.
Option A, during delivery through mixing of blood, is correct as HIV can be transmitted through exposure to infected blood during childbirth. Option B, during pregnancy through placenta, is also correct as the virus can cross the placenta and infect the fetus. Option C, via breastmilk during lactation, is correct as HIV can be present in breastmilk and transmitted to the child through breastfeeding.
Therefore, the preferred mode of transmission of HIV from a mother to a child
Question 5
A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
A. Patient will have one soft, formed bowel movement by end of shift.
B. Patient will walk unassisted to bathroom by the end of shift.
C. Patient will be offered laxatives or stool softeners this shift.
D. Patient will not take any pain medications this shift.
Show answer and rationale
Correct answer: A — Patient will have one soft, formed bowel movement by end of shift.
The correct answer is A. The most appropriate outcome for the nurse to include in the plan of care is for the patient to have one soft, formed bowel movement by the end of the shift. This outcome directly addresses the nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. By aiming for a soft, formed bowel movement, the nurse is working towards alleviating the constipation issue caused by the pain medications. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART), making it an appropriate goal for the patient's care plan.
Choice B is incorrect because walking unassisted to the bathroom does not directly address the constipation issue. Choice C is incorrect as offering laxatives or stool softeners is a nursing intervention and not an outcome. Choice D is incorrect as withholding pain medications may not be in the best interest of the patient's overall care and does not directly target the constipation issue.
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Question 6
A patient is noted to be bending over backward in the group room. A peer asks what he is doing, and he replies, 'People say they are bending over backwards to help me, so I am bending over backwards to help myself.' This is an example of:
A. abstract thinking.
B. concrete thinking.
C. impaired reality testing.
D. boundary impairment.
Correct answer:
The correct answer is B: concrete thinking. Concrete thinking refers to interpreting things in a literal or straightforward manner without grasping abstract concepts or metaphors. In this scenario, the patient is taking the expression "bending over backward" literally, demonstrating a lack of understanding of its figurative meaning.
A: Abstract thinking involves understanding complex concepts and interpreting information beyond the literal meaning. The patient's response does not demonstrate abstract thinking.
C: Impaired reality testing refers to an inability to distinguish between what is real and what is not. The patient's response does not suggest a detachment from reality.
D: Boundary impairment involves difficulty in recognizing and maintaining personal boundaries. The patient's response does not relate to boundary issues.
In summary, the patient's literal interpretation of the expression "bending over backward" reflects concrete thinking, making choice B the correct answer.
Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?
A. Assisting with a naloxone challenge test before therapy begins
B. Discontinuing the drug immediately if signs of dependence appear
C. Changing the administration route to P.O. if the client can tolerate fluids
D. Obtaining baseline vital signs before administering the first dose
Correct answer:
The correct answer is D: Obtaining baseline vital signs before administering the first dose. This intervention is crucial to establish the client's baseline condition before starting morphine therapy. Baseline vital signs provide a comparison for monitoring the client's response to the medication and detecting any adverse effects. This step ensures the nurse can identify and address any potential complications promptly.
Other choices are incorrect:
A: Assisting with a naloxone challenge test before therapy begins - Naloxone challenge test is used to diagnose opioid dependence, not appropriate for monitoring pain management.
B: Discontinuing the drug immediately if signs of dependence appear - Abrupt discontinuation can lead to withdrawal symptoms and should be managed gradually.
C: Changing the administration route to P.O. if the client can tolerate fluids - Changing the route of administration should be based on clinical indications, not solely on the client's ability to tolerate fluids.
A gravida 1 para 0 who is 10 weeks pregnant has her first prenatal visit. After performing a history and physical, which test ordered by the physician should the nurse verify with the examiner?
A. Serological test for syphilis
B. Rubella vaccine
C. Clean-catch urinalysis
D. Abdominal ultrasound
Correct answer:
The correct answer is D: Abdominal ultrasound. At 10 weeks gestation, an abdominal ultrasound is typically ordered to confirm the viability of the pregnancy, assess fetal development, and determine gestational age. This test allows the healthcare provider to visualize the fetus, placenta, and amniotic fluid. It is essential in monitoring the progress of the pregnancy and identifying any potential complications.
Rationale for other choices:
A: Serological test for syphilis - While this test is important in prenatal care to screen for syphilis, it is usually done as part of routine prenatal blood work and not typically verified immediately after the first visit.
B: Rubella vaccine - Administering the rubella vaccine during pregnancy is contraindicated as it poses a risk to the developing fetus.
C: Clean-catch urinalysis - While urinalysis is a common test in prenatal care to screen for urinary tract infections and other conditions, it is not typically the first test verified following
Schemata, automatic thoughts, and cognitive distortions are terms that relate to:
A. Rational-emotive behavioral therapy.
B. Cognitive-behavioral therapy.
C. Operant conditioning theory.
D. Biofeedback.
Correct answer:
The correct answer is B: Cognitive-behavioral therapy. Schemata, automatic thoughts, and cognitive distortions are central concepts in cognitive-behavioral therapy (CBT). In CBT, schemata are core beliefs, automatic thoughts are immediate cognitive responses to situations, and cognitive distortions are irrational thought patterns. CBT aims to identify and challenge these cognitive processes to promote healthier thinking patterns and behaviors.
Incorrect choices:
A: Rational-emotive behavioral therapy focuses on challenging irrational beliefs and is related to CBT, but does not specifically address schemata, automatic thoughts, and cognitive distortions.
C: Operant conditioning theory focuses on learning through reinforcement and punishment, not cognitive processes like schemata and automatic thoughts.
D: Biofeedback is a technique to help individuals control physiological processes, such as heart rate or muscle tension, and is not directly related to cognitive processes addressed in CBT.
In the socioenvironmental model, the focus of the health care provider includes:
A. changing the patient's perceptions of disease.
B. identification of biomedical model interventions.
C. identifying the negative health behaviours of the patient.
D. helping the patient view health as a resource.
Correct answer:
The correct answer is D because in the socioenvironmental model, the health care provider aims to help the patient view health as a resource. This approach emphasizes empowering patients to take control of their health by recognizing it as an asset that enables them to lead fulfilling lives. By focusing on health as a resource, the provider encourages positive health behaviors and preventive measures.
A, changing the patient's perceptions of disease, is incorrect because the socioenvironmental model does not solely target disease perceptions but rather prioritizes health promotion.
B, identification of biomedical model interventions, is incorrect as the socioenvironmental model places more emphasis on holistic and social determinants of health rather than solely biomedical interventions.
C, identifying the negative health behaviors of the patient, is also incorrect as the model aims to address health behaviors in a positive and empowering way rather than focusing solely on negatives.
The nurse is providing care in PACU for a patient who just delivered a neonate via cesarean section. The patient reports tightness in her chest. Assessment findings include tachypnea, hypotension, and decreasing oxygen saturation levels. Which complication does the nurse report to the health care provider?
A. Pulmonary embolism
B. Postpartum hemorrhage
C. Surgical-site infection
D. Developing endometritis
Correct answer:
The correct answer is A: Pulmonary embolism. The patient's symptoms of chest tightness, tachypnea, hypotension, and decreasing oxygen saturation levels are indicative of a potential pulmonary embolism, which is a serious complication post-cesarean section. A pulmonary embolism occurs when a blood clot travels to the lungs, causing respiratory distress and cardiovascular compromise. The nurse should report this immediately to the healthcare provider for prompt intervention to prevent further complications.
Incorrect choices:
B: Postpartum hemorrhage - Symptoms of postpartum hemorrhage include excessive bleeding, not chest tightness and respiratory distress.
C: Surgical-site infection - Symptoms of surgical-site infection include redness, swelling, and drainage at the incision site, not chest tightness and respiratory distress.
D: Developing endometritis - Symptoms of endometritis include fever, pelvic pain, and abnormal vaginal discharge, not chest tightness and respiratory distress.
A nurse is caring for a patient in labor who is experiencing intense pain. Which of the following would be the most appropriate intervention to manage pain during labor?
A. Encourage the patient to practice deep breathing and relaxation techniques.
B. Administer intravenous fluids to reduce pain sensation.
C. Provide a sedative to help the patient rest between contractions.
D. Suggest an epidural to block pain completely.
Correct answer:
The correct answer is A: Encourage the patient to practice deep breathing and relaxation techniques. This is the most appropriate intervention to manage pain during labor because deep breathing and relaxation techniques can help the patient to cope with the pain, reduce stress, and promote a sense of control. These techniques are safe, non-invasive, and can be effective in managing labor pain without the need for medication or invasive procedures.
Summary:
- Choice B (Administer intravenous fluids): Intravenous fluids do not directly reduce pain sensation and are not a primary intervention for managing labor pain.
- Choice C (Provide a sedative): Sedatives may affect the baby and can interfere with the progress of labor. They do not address the root cause of pain during labor.
- Choice D (Suggest an epidural): While epidurals can provide effective pain relief, they are not always necessary or desired by all patients. Encouraging non-pharmacological methods first is often preferred.
When should a child receive the first dose of the hepatitis B virus (HBV) vaccine if the mother is hepatitis B surface antigen (HBsAg) negative?
A. 2 months of age, before hospital discharge.
B. Birth before discharge from the hospital.
C. 6 months of age, at the third well-child visit.
D. No time (this vaccine is not currently recommended).
Correct answer:
If the mother is HBsAg negative, it is recommended that the child receives the first dose of the hepatitis B vaccine at birth before discharge from the hospital. This is to provide early protection against the hepatitis B virus. The second dose of the vaccine is typically given at the first well-child visit, and the third dose is usually administered at a later date. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the Committee on Infectious Diseases of the American Academy of Pediatrics govern the recommendations for immunization, including the hepatitis B virus vaccine. Choice A is incorrect as the first dose should ideally be given at birth. Choice C is incorrect as waiting until 6 months of age may leave the child vulnerable to infection during the early months of life. Choice D is incorrect as the hepatitis B vaccine is recommended for all newborns, especially if the mother is HBsAg negative, to prevent transmission of the virus.
A patient is scheduled for enucleation and the nurse is providing anticipatory guidance about postoperative care. What aspects of care should the nurse describe to the patient? Select all that apply.
A. Application of topical antibiotic ointment
B. Maintenance of a supine position for the first 48 hours postoperative
C. Fluid restriction to prevent orbital edema
D. Administration of loop diuretics to prevent orbital edema E) Use of an ocular pressure dressing Chapter 64: Ear/Hearing: Hearing tests, Hearing loss, Otitis externa, Otitis media, Trauma, Meniere’s disease, Mastoidectomy – perioperative care, Impacted cerumen & Cochlear implant
Correct answer:
The correct answer is A: Application of topical antibiotic ointment. After enucleation, there is a risk of infection at the surgical site. By applying topical antibiotic ointment as directed, the patient can help prevent infection and promote healing. This is a crucial aspect of postoperative care.
B: Maintenance of a supine position for the first 48 hours postoperative is incorrect. Patients may be advised to avoid lying flat on their back to prevent complications such as pressure on the surgical site.
C: Fluid restriction to prevent orbital edema is incorrect. Fluid restriction is not typically necessary post-enucleation unless specifically advised by the healthcare provider.
D: Administration of loop diuretics to prevent orbital edema is incorrect. Loop diuretics are not typically used for preventing orbital edema post-enucleation.
E: Use of an ocular pressure dressing is incorrect. While dressings may be used postoperatively, the application of topical antibiotic ointment is more
The nurse is performing a well-child assessment on a 15-month-old child. The child's mother and father are present. Which action by the nurse will best determine the health beliefs and values of the parents?
A. Have the parents independently complete the Myers-Briggs Type Indicator survey.
B. Read the documented health histories of the child's parents and grandparents.
C. Actively listen to the parents talk about their lives and health concerns.
D. Review the traditional health practices of the ethnic group identified by the parents.
Correct answer:
The correct answer is C: Actively listen to the parents talk about their lives and health concerns. This action allows the nurse to directly learn about the parents' health beliefs and values. By listening attentively, the nurse can understand the parents' perspectives, concerns, and priorities regarding their child's health. This approach promotes trust and open communication, enabling the nurse to provide individualized and culturally sensitive care.
Explanation for why the other choices are incorrect:
A: Having the parents complete the Myers-Briggs Type Indicator survey is not relevant to determining their health beliefs and values.
B: Reading the health histories of the child's parents and grandparents may provide some background information but may not reflect their current health beliefs and values.
D: Reviewing traditional health practices of the ethnic group identified by the parents assumes that all individuals within that group hold the same beliefs, which may not be accurate.
RN exams 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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