RN exams clinical judgment practice questions, set 40
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 40
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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
Andrew, a New York City firefighter, and his entire unit responded to the terrorist attacks at the World Trade Center. Working as a team, he and his best friend, Carlo, entered the area together. Carlo was killed when the building collapsed. Andrew was injured, but survived. Since that time, Andrew has had frequent nightmares and anxiety attacks. He says to the mental health worker, 'I don’t know why Carlo had to die and I didn’t!' This statement by Andrew suggests that he is experiencing:
A. Spiritual distress
B. Night terrors
C. Survivor’s guilt
D. Suicidal ideation
Show answer and rationale
Correct answer: C — Survivor’s guilt
The correct answer is C: Survivor's guilt. Andrew's statement indicates feelings of guilt and confusion about why he survived while Carlo did not. Survivor's guilt is a common psychological response in individuals who have lived through a traumatic event where others did not. Andrew's frequent nightmares and anxiety attacks are also typical symptoms of survivor's guilt.
A: Spiritual distress is not the correct answer in this scenario as Andrew's statement does not specifically reference any spiritual or religious beliefs or conflicts.
B: Night terrors may be a symptom of Andrew's PTSD, but his statement about not understanding why he survived while Carlo did not suggests a deeper emotional struggle beyond just experiencing night terrors.
D: Suicidal ideation is not the correct answer as Andrew's statement does not indicate any desire or intention to harm himself. Rather, he is expressing confusion and guilt about surviving the traumatic event.
Question 2
A group is in the working phase. One member says, That is the stupidest thing Ive ever heard. Everyone whines and tells everyone else what to do. This group is a total waste of my time. Which comment by the group leader would be most therapeutic?
A. You seem to think you know a lot already. Since you know so much, perhaps you can tell everyone why you are back in the hospital?
B. I think you have made your views clear, but I wonder if others feel the same way. How does everyone else feel about our group?
C. It must be hard to be so angry. Direct this comment to another group member, You were also angry at first but not now. What has helped you?
D. I would like to remind you that one of our group rules is that everyone is to offer only positive responses to the comments of others.
Show answer and rationale
Correct answer: C — It must be hard to be so angry. Direct this comment to another group member, You were also angry at first but not now. What has helped you?
The members comments demean the group and its members and suggest that the member is very angry. Labeling the emotion and conveying empathy would be therapeutic. Focusing on members who are likely to be more positive can balance the influence of demoralizing members. You seem to know a lot conveys hostility from the leader, who confronts and challenges the member to explain how he came to be readmitted if he was so knowledgeable, implying that he is less knowledgeable than he claims. This comment suggests countertransference and is non-therapeutic. Shifting away from the complaining member to see if others agree seeks to have others express disagreement with this member, but that might not happen. In the face of his anger, they might be quiet or afraid to oppose him, or they could respond in kind by expressing hostility themselves. A rule that only positive exchanges are permitted would suppress conflict, reducing the effectiveness of the therapy group.
Question 3
Which instruction should the nurse provide to an elderly client who is taking an ACE inhibitor and a calcium channel blocker?
A. Wear long-sleeved clothing when outdoors
B. Report the onset of sore throat
C. Eat plenty of potassium-rich food
D. Change the position slowly
Show answer and rationale
Correct answer: D — Change the position slowly
The correct answer is D: Change the position slowly. Elderly clients taking both ACE inhibitors and calcium channel blockers are at risk for orthostatic hypotension. Instructing them to change positions slowly helps prevent sudden drops in blood pressure and dizziness upon standing up.
A: Wearing long-sleeved clothing when outdoors is not directly related to the medications mentioned.
B: Reporting the onset of a sore throat is important for monitoring potential side effects of medications but not specific to the combination of ACE inhibitors and calcium channel blockers.
C: Eating plenty of potassium-rich foods is not typically contraindicated for clients taking ACE inhibitors and calcium channel blockers, but it is not the most essential instruction compared to preventing orthostatic hypotension.
In summary, changing position slowly is crucial to prevent orthostatic hypotension, which is a common side effect of these medications in elderly clients.
Question 4
A group is in the working phase. One member says, That is the stupidest thing Ive ever heard. Everyone whines and tells everyone else what to do. This group is a total waste of my time. Which comment by the group leader would be most therapeutic?
A. You seem to think you know a lot already. Since you know so much, perhaps you can tell everyone why you are back in the hospital?
B. I think you have made your views clear, but I wonder if others feel the same way. How does everyone else feel about our group?
C. It must be hard to be so angry. Direct this comment to another group member, You were also angry at first but not now. What has helped you?
D. I would like to remind you that one of our group rules is that everyone is to offer only positive responses to the comments of others.
Show answer and rationale
Correct answer: C — It must be hard to be so angry. Direct this comment to another group member, You were also angry at first but not now. What has helped you?
The members comments demean the group and its members and suggest that the member is very angry. Labeling the emotion and conveying empathy would be therapeutic. Focusing on members who are likely to be more positive can balance the influence of demoralizing members. You seem to know a lot conveys hostility from the leader, who confronts and challenges the member to explain how he came to be readmitted if he was so knowledgeable, implying that he is less knowledgeable than he claims. This comment suggests countertransference and is non-therapeutic. Shifting away from the complaining member to see if others agree seeks to have others express disagreement with this member, but that might not happen. In the face of his anger, they might be quiet or afraid to oppose him, or they could respond in kind by expressing hostility themselves. A rule that only positive exchanges are permitted would suppress conflict, reducing the effectiveness of the therapy group.
Question 5
The nurse is caring for a 16-year-old patient who is 32 weeks pregnant with her first child, who is male. The patient's mother has accompanied her to today's visit. During the nursing assessment, the patient mentions that she is no longer in a relationship with the baby's father but her mother plans to help her. However, the patient's mother asks whether this will have any impact on the child. Which should the nurse indicate the child is at increased risk of during his adolescence?
A. Hypertension
B. Diabetes
C. Alcohol abuse
D. Intraventricular bleeding
Show answer and rationale
Correct answer: C — Alcohol abuse
The correct answer is C: Alcohol abuse. During adolescence, children of parents who have substance abuse issues, like alcohol, are at an increased risk of developing similar problems. This is due to genetic predisposition, environmental factors, and learned behavior. Children tend to model the behavior of their parents, and if they are exposed to alcohol abuse at a young age, they are more likely to engage in alcohol abuse themselves as they grow older.
Incorrect choices:
A: Hypertension - This choice is not directly related to the situation described and is not typically a risk factor associated with parental alcohol abuse.
B: Diabetes - Similar to choice A, diabetes is not directly linked to parental alcohol abuse and is not a common risk factor during adolescence in this scenario.
D: Intraventricular bleeding - This is a medical condition that is not typically influenced by parental alcohol abuse and is not a common risk factor during adolescence.
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Question 6
Mr. Costigan is a 50-year-old male patient who recently had a screening colonoscopy because it was recommended by his primary care provider as a screening measure. He received a report that noted inflammatory polyps. He is concerned because one of his friends had polyps that turned into cancer. While advising Mr. Costigan, the AGACNP tells him that
A. The polyps are considered precancerous, but if he has a colonoscopy every 3 to 5 years, any new polyps can be removed before they become malignant
B. The primary danger is when there is a family history of colon cancer; he should discuss with his mother and father the presence of any colon cancer in the family
C. There is no chance that these polyps could become cancerous, and their presence does not require any additional action or concern on his part
D. He would be best served at this point to discuss with an oncologist the risks and benefits of aggressive versus conservative treatment.
Correct answer:
Step 1: Family history of colon cancer is a significant risk factor for developing colon cancer.
Step 2: By discussing with his parents, Mr. Costigan can determine if there is a family history of colon cancer.
Step 3: Knowing this information can help assess his own risk and guide appropriate screening and preventive measures.
Step 4: The primary danger for Mr. Costigan lies in potential genetic predisposition rather than the presence of inflammatory polyps.
Step 5: Therefore, discussing with family members about any history of colon cancer is crucial for his overall risk assessment and management.
Summary:
- Choice A is incorrect as the frequency of colonoscopy should be individualized based on the patient's risk factors.
- Choice C is incorrect as all polyps have the potential to become cancerous, especially inflammatory polyps.
- Choice D is incorrect as consulting an oncologist at this stage is premature without first assessing family history.
A nurse is educating a postpartum person about newborn care. What is the best way to prevent diaper rash?
A. frequent diaper changes
B. use of a barrier cream
C. apply petroleum jelly to the skin
D. change diapers frequently
Correct answer:
The correct answer is C: apply petroleum jelly to the skin. Petroleum jelly acts as a barrier, protecting the baby's skin from moisture and irritants in the diaper. It helps maintain the skin's natural moisture and prevents diaper rash.
Rationale:
1. Petroleum jelly creates a protective barrier on the skin, preventing direct contact with moisture and irritants.
2. It helps to keep the skin moisturized, reducing the risk of irritation.
3. Petroleum jelly is safe and gentle on the baby's skin.
4. It is particularly effective for preventing diaper rash compared to other options.
Summary:
A: Frequent diaper changes are important but may not provide enough protection against moisture and irritants.
B: Barrier creams can be effective, but petroleum jelly is a more commonly recommended option.
D: Changing diapers frequently is essential, but applying petroleum jelly as an additional protective measure is more effective in preventing diaper rash.
Nurses identifying outcomes and related nursing interventions must refer to the standards and agency policies for setting priorities, identifying and recording expected client outcomes, selecting evidence-based nursing interventions, and recording the plan of care. Which of the following are recognized standards?
A. Professional physicians’ organizations
B. State Nurse Practice Acts
C. The Joint Commission
D. The Agency for Health Care Research and Quality
Correct answer:
Correct Answer: B (State Nurse Practice Acts)
Rationale: State Nurse Practice Acts outline the legal scope of nursing practice, including standards for setting priorities, identifying client outcomes, and selecting evidence-based nursing interventions. These laws are specific to nursing practice, ensuring that nurses follow guidelines tailored to their profession. Nurses must adhere to these standards to provide safe and effective care.
Summary of Incorrect Choices:
A: Professional physicians' organizations - While physicians' organizations may provide guidelines for medical practice, they do not set standards specific to nursing practice.
C: The Joint Commission - The Joint Commission focuses on accreditation for healthcare organizations, not setting standards for nursing practice.
D: The Agency for Health Care Research and Quality - AHRQ conducts research and provides evidence-based information but does not establish standards for nursing practice.
A nurse believes a new mouth care procedure (MCP) is causing more mouth problems than it
A. Which of the following must be present for the nurse to go to administration with confidence that the MCP is causing problems? (Select all that apply.)
B. A plausible explanation of how the new MCP could cause harm
C. A strong feeling that the MCP is the cause
D. Consistently seeing mouth inflammation in many of the patients who have received the MCP
Correct answer:
Rationale for Correct Answer (B): A plausible explanation of how the new MCP could cause harm is crucial for the nurse to confidently present concerns to administration. Without understanding how the MCP could be causing issues, it would be challenging to convince administration of the need for changes. This step ensures that the nurse has a solid basis for their argument and can clearly articulate the potential risks associated with the new procedure.
Summary of Incorrect Choices:
A: While having specific criteria present can strengthen the case, it is not the primary factor for determining if the MCP is causing problems.
C: Relying solely on personal feelings or intuition is not sufficient evidence to support the claim that the MCP is causing harm.
D: Observing consistent mouth inflammation is important but does not provide a clear causal relationship between the MCP and the issues, lacking the necessary explanation of how harm is being caused.
Afamilywhosereligionlimitstheuseofsomeformsoftechnologyisadmittingtheirgrandfatherto youurunit.Theyexpressskepticismaboutthefactthatyouarerecordingtheadmissiondataonalaptop computer.Whatwouldbeyourbestresponsetotheirconcerns? N
A. Itsbeenfoundthatusingcomputersimprovesourpatientscareandreducestheirhealthcarecosts.
B. Wehavefoundthatitiseasiertokeeptrackofourpatientsinformationthiswayratherthanwith penandpaper.
C. Youll find that all the hospitals are doing this now, and that writing information with a pen is rar
Correct answer:
Step-by-step rationale for why answer B is correct:
1. Privacy and accuracy: Storing patient information on a computer allows for better organization and security compared to pen and paper.
2. Accessibility: Electronic records can be easily accessed and updated by authorized personnel.
3. Efficiency: Retrieving and sharing patient data is quicker and more efficient with digital records.
4. Compliance: Using electronic health records aligns with modern healthcare standards and regulations.
5. Patient care: By maintaining accurate and easily accessible records, healthcare providers can deliver better and more coordinated care.
Summary of why other choices are incorrect:
A: Focuses on patient care and cost reduction, not directly addressing the family's concerns about technology use.
C: Appeals to common practice and technology trends, but does not address the family's specific concerns about their beliefs.
D: Incomplete answer, no rationale provided.
A postpartum client is getting ready to receive a Depo-Provera injection. Which statement by the client indicates that further teaching by the nurse is necessary?
A. You will give this shot just like the rubella injection I received yesterday.
B. I will watch my weight and try to exercise daily after receiving this injection.
C. I will need to reschedule a follow-up appointment in 3 months.
D. It might take me a year to get pregnant after receiving this type of birth control.
Correct answer:
The correct answer is A because the client's comparison of receiving a Depo-Provera injection to a rubella injection is incorrect. Depo-Provera is a hormonal contraceptive injection that does not have the same administration process or purpose as a rubella vaccination. This indicates a lack of understanding about the medication.
Choice B is not the correct answer because it shows the client's awareness of the importance of weight management and exercise in conjunction with receiving the injection.
Choice C is not the correct answer because it demonstrates the client's understanding of the need for a follow-up appointment in 3 months which is necessary for monitoring and continuation of the contraceptive method.
Choice D is not the correct answer because it shows the client's understanding of the potential delay in fertility after discontinuing Depo-Provera, which is an important aspect of the contraceptive method that the client should be aware of.
A pregnant patient is 26 weeks gestation and reports difficulty breathing when lying flat. What should the nurse recommend?
A. Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm.
B. Recommend sleeping in a fully reclined position to prevent shortness of breath.
C. Administer oxygen as prescribed to ensure proper oxygenation.
D. Instruct the patient to lie flat on her back and use a pillow for support.
Correct answer:
The correct answer is A: Encourage the patient to sleep on the left side to improve circulation and reduce pressure on the diaphragm. At 26 weeks gestation, the uterus can compress the inferior vena cava when lying flat on the back, leading to decreased blood return to the heart and reduced cardiac output, causing difficulty breathing. Sleeping on the left side helps improve circulation by reducing pressure on the vena cava, enhancing blood flow and oxygenation to the fetus and mother.
Incorrect options:
B: Recommending sleeping in a fully reclined position may not alleviate the compression on the vena cava and could potentially worsen the patient's symptoms.
C: Administering oxygen may help with oxygenation but does not address the underlying issue of vena cava compression due to the growing uterus.
D: Instructing the patient to lie flat on her back can exacerbate the issue by further compressing the vena cava, worsening breathing difficulties.
A 28-year-old Aboriginal woman attending a prenatal visit describes her nutritional intake over the past 24 hours to the nurse. It includes two slices of pizza, two cans of soda, and three cookies. The nurse must:
A. advise the patient that she is not eating the required recommended nutritional intake for pregnancy.
B. show the patient how to document her food intake, as she may start gaining unnecessary weight.
C. ask the patient if she is able to cook, or if she would like to go grocery shopping.
D. discuss how the patient's food choices may affect her health and that of her baby.
Correct answer:
The correct answer is D: discuss how the patient's food choices may affect her health and that of her baby. This is the most appropriate response because it addresses the potential impact of the patient's current diet on her health and the health of her baby during pregnancy. By discussing the implications of her food choices, the nurse can educate the patient on the importance of a balanced and nutritious diet for a healthy pregnancy. This approach promotes awareness and empowers the patient to make informed decisions for her and her baby's well-being.
Incorrect choices:
A: This option does not provide guidance or education on improving the patient's diet, which is crucial for a healthy pregnancy.
B: Focusing on weight gain rather than nutritional content may not address the underlying issue of poor dietary choices.
C: Assuming the patient's ability to cook or go grocery shopping may not address the immediate need for dietary education and guidance.
A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?
A. Assessment
B. Analysis
C. Implementation
D. Evaluation
Correct answer:
The correct answer is D: Evaluation. In the nursing process, evaluation is the final step where the nurse determines if the goals and outcomes of care have been achieved. In this scenario, the nurse is assessing the client's condition before discharge to ensure there are no signs of thrombophlebitis. The absence of pain, redness, and edema indicates successful treatment. This step aligns with the evaluation phase as the nurse is assessing the client's response to treatment.
A: Assessment is incorrect because the nurse has already assessed the client's leg and is now determining the effectiveness of the treatment.
B: Analysis is incorrect as this step involves interpreting the data collected during assessment to identify problems and make nursing diagnoses.
C: Implementation is incorrect as this step involves carrying out the nursing interventions to achieve the established goals. The nurse has already implemented the treatment plan in this scenario.
Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?
A. An 18-year-old college student with type 1 diabetes who exercises excessively
B. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning
C. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections
D. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza
Correct answer:
The correct answer is D because the 83-year-old long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza is at the highest risk for hyperosmolar hyperglycemic syndrome (HHS). This patient has multiple risk factors for HHS, including age, type 2 diabetes, advanced Alzheimer's disease, and the added stress of influenza, which can exacerbate hyperglycemia. The combination of these factors can lead to severe hyperglycemia, dehydration, and electrolyte imbalances characteristic of HHS.
Choice A is incorrect because although excessive exercise can lead to hypoglycemia in individuals with type 1 diabetes, it is not a risk factor for HHS. Choice B is incorrect as forgetting to take insulin can lead to diabetic ketoacidosis in type 1 diabetes, not HHS. Choice C is incorrect as starting insulin injections in a patient with type 2 diabetes and coronary artery disease does not automatically increase the risk
RN exams clinical judgment practice questions, set 40 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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