RN exams clinical judgment practice questions, set 64
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 64
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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
K. T. presents for a routine wellness examination, and the review of systems is significant only for a markedly decreased capacity for intake and a vague sense of nausea after eating. K. T. denies any other symptoms the remainder of the GI review of systems is negative. His medical history is significant for complicated peptic ulcer disease that finally required resection for a perforated ulcer. The AGACNP advises the patient that
A. He will need endoscopy to evaluate the problem
B. Chronic gastroparesis is a known complication of ulcer surgery
C. Medication is unlikely to help, and he may need another surgery
D. His symptoms occur in 5 to 10% of people after ulcer surgery
Show answer and rationale
Correct answer: C — Medication is unlikely to help, and he may need another surgery
Rationale for Correct Answer (C):
1. The patient's symptoms of decreased capacity for intake and nausea after eating suggest gastroparesis, a common complication post-ulcer surgery.
2. Given the history of complicated peptic ulcer disease and prior surgery, medication may be ineffective, necessitating potential reoperation.
3. The AGACNP advises that another surgery may be needed, indicating that medication alone may not suffice to address the issue.
Summary of Incorrect Choices:
A: Endoscopy is not necessary at this point as the symptoms are likely indicative of a functional issue rather than a structural problem.
B: While gastroparesis can occur post-ulcer surgery, the patient's symptoms are more suggestive of gastroparesis rather than chronic gastroparesis as a known complication.
D: The frequency of occurrence of symptoms after ulcer surgery is not relevant to the current management of the patient's symptoms.
Question 2
The nurse is caring for a patient who is to begin receiving external radiation for a malignant tumor of the neck. While providing patient education, what potential adverse effects should the nurse discuss with the patient?
A. Impaired nutritional status
B. Cognitive changes
C. Diarrhea
D. Alopeci
Show answer and rationale
Correct answer: A — Impaired nutritional status
The correct answer is A: Impaired nutritional status. Radiation therapy to the neck can lead to mucositis, dysphagia, and taste changes, which can impair the patient's ability to eat and maintain adequate nutrition. This can lead to weight loss, weakness, and delayed wound healing. Discussing this potential adverse effect with the patient is crucial for proactive management.
Choice B: Cognitive changes, and Choice C: Diarrhea are less likely to be direct adverse effects of radiation therapy to the neck. Cognitive changes are more commonly associated with brain radiation, while diarrhea is a more common side effect of abdominal radiation.
Choice D: Alopecia is a side effect of chemotherapy, not radiation therapy. Radiation therapy does not typically cause hair loss unless it is in the treatment field. Therefore, discussing alopecia with the patient receiving radiation for a malignant neck tumor is not a priority.
Question 3
The nurse practitioner assesses a client in the physician’s office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)?
A. Facial erythema, profuse proteinuria, pleuritis, fever, and weight loss
B. Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers
C. Weight gain, hypervigilance, hypothermia, and edema of the legs
D. Hypothermia, weight gain, lethargy, and edema of the arms
Show answer and rationale
Correct answer: B — Pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers
The correct answer is B because the assessment findings of pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers are classic manifestations of systemic lupus erythematosus (SLE). Pericarditis can present as chest pain aggravated by deep breathing or lying flat, photosensitivity refers to skin rashes triggered by sunlight exposure, polyarthralgia involves joint pain in multiple joints, and painful mucous membrane ulcers are common in the mouth or nose. These findings align with the diagnostic criteria for SLE.
Choices A, C, and D are incorrect because they do not align with the typical presentation of SLE. Choice A includes facial erythema which is a common symptom, but the presence of profuse proteinuria, pleuritis, fever, and weight loss are not specific to SLE. Choices C and D include symptoms like weight gain, hypothermia, and edema which are not characteristic of SLE.
In summary
Question 4
The hospital nurse educator develops an educational session for staff nurses on how to clearly record data in a patient's electronic medical record. Which key point should the nurse educator include in the teaching plan? (Select all that apply)
A. A patient who is at high risk for falls will require more frequent documentation.
B. The nurse should avoid labels (e.g., good, drug seeking, and lazy) to describe patients.
C. Detailed and specific documentation is only required if a malpractice suit is expected.
D. Each entry by the nurse in the electronic medical record should be clear and concise.
Show answer and rationale
Correct answer: A — A patient who is at high risk for falls will require more frequent documentation.
The correct answer is A because documenting the frequency of assessments and interventions for high-risk patients, such as those at risk for falls, is crucial for patient safety and care coordination. By documenting more frequently for high-risk patients, nurses can ensure timely interventions and prevent adverse events. This practice aligns with the principles of patient-centered care and risk management.
Choices B, C, and D are incorrect:
B: Avoiding labels in documentation is important for professionalism and ethical practice, but it is not directly related to the frequency of documentation for high-risk patients.
C: Detailed and specific documentation is required for all patients to ensure comprehensive care, not just for potential malpractice suits.
D: While clear and concise documentation is essential, this choice does not specifically address the need for more frequent documentation for high-risk patients.
Question 5
After morphine administration the nurse should closely observe for the following sign of side effect:
A. Nausea
B. Respiratory depression
C. Constipation
D. Restlessness
Show answer and rationale
Correct answer: B — Respiratory depression
The correct answer is B: Respiratory depression. Morphine is an opioid that can cause respiratory depression as a side effect by suppressing the respiratory drive in the brainstem. This can lead to decreased breathing rate and depth, potentially causing hypoxia and respiratory failure. It is crucial for the nurse to closely monitor the patient's respiratory status after morphine administration to prevent any complications.
Incorrect choices:
A: Nausea - Nausea is a common side effect of opioids like morphine, but it is not as critical or life-threatening as respiratory depression.
C: Constipation - Constipation is another common side effect of opioids due to decreased gastrointestinal motility, but it is not an immediate concern compared to respiratory depression.
D: Restlessness - Restlessness is not a common side effect of morphine and is not as serious as respiratory depression in terms of patient safety.
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Question 6
A nursing student is asked to set goals that will decrease the fetal death outcomes during delivery. What guidelines will the nursing student use to assist in setting her goals?
A. WHO Maternal care guidelines
B. Healthy People 2020
C. AWHONN white papers
D. State Practice Act
Correct answer:
The correct answer is B: Healthy People 2020. This is because Healthy People 2020 provides specific objectives related to maternal and child health, including reducing fetal death outcomes during delivery. The goals and targets outlined in Healthy People 2020 are evidence-based and nationally recognized, making it a reliable guide for setting healthcare goals.
A: WHO Maternal care guidelines focus more broadly on global maternal health issues and may not provide specific goals related to reducing fetal death outcomes during delivery.
C: AWHONN white papers may offer valuable insights and recommendations, but they are not as comprehensive or widely recognized as the goals outlined in Healthy People 2020.
D: State Practice Acts govern the scope of practice for healthcare providers in a specific state, but they do not typically include specific goals related to reducing fetal death outcomes during delivery.
Unlike psychophysiologic disorder Linda may be best managed with:
A. Medical regimen
B. Milieu therapy
C. Stress management technique.
D. Psychotherapy
Correct answer:
Step-by-step rationale for choice C (Stress management technique) being correct:
1. Linda's condition involves psychological factors contributing to physical symptoms.
2. Stress management techniques help address the underlying stress that may exacerbate her symptoms.
3. Techniques such as relaxation exercises and cognitive-behavioral therapy can help Linda cope with stress.
4. By managing stress effectively, Linda can reduce the frequency and severity of her symptoms.
Summary of why other choices are incorrect:
A. Medical regimen: Linda's condition is primarily psychological, so solely focusing on medications may not address the root cause.
B. Milieu therapy: This therapy focuses on the environment, which may not directly target Linda's stress and psychological factors.
D. Psychotherapy: While psychotherapy is beneficial, stress management techniques specifically target stressors that may worsen Linda's symptoms.
A nurse is meeting with a new client at a substance use disorder clinic. During the meeting, the client states that they have been using cocaine at least once daily for the past 6 months. The nurse is collecting which of the following types of data from the client's account?
A. Subjective
B. Secondary
C. Historical
D. Objective
Correct answer:
The correct answer is A: Subjective. Subjective data is information provided by the client, based on their personal experiences and feelings. In this scenario, the client's statement about using cocaine daily is their personal account, making it subjective data. The nurse is gathering this information directly from the client's perspective.
Summary:
B: Secondary data refers to information collected from sources other than the client, such as medical records or research studies.
C: Historical data pertains to past events and may include information about the client's substance use history, but it does not capture the client's current experiences as directly as subjective data.
D: Objective data is measurable and observable, typically collected through physical assessments or laboratory tests. In this case, the client's statement about cocaine use is not objective data as it is based on their personal account.
A 44-year-old woman presents with an unexpected pregnancy. She asks the nurse, 'Is my baby going to have a birth defect? My third cousin has Down syndrome.' What is the nurse's best response?
A. Tell the patient she is at risk for gene mutation because a birth defect in a distant relative places the woman at increased risk.
B. Discuss the potential risk for intrauterine growth retardation due to the mother's advanced age.
C. Discuss the patient's situation with the physician to ask for a referral to high-risk obstetrics.
D. Discuss the potential risk for a chromosomal abnormality based on the patient's advanced age.
Correct answer:
Step 1: The correct answer is D because advanced maternal age (AMA), generally defined as 35 years or older, is a well-known risk factor for chromosomal abnormalities, such as Down syndrome.
Step 2: Down syndrome is more common in babies born to mothers over the age of 35 due to the increased likelihood of errors in cell division during egg development.
Step 3: Given the patient's age of 44, she falls into the category of AMA and is at an increased risk for chromosomal abnormalities in her baby.
Step 4: Option A is incorrect as the risk is not solely based on gene mutation but rather on the increased chance of chromosomal abnormalities due to age.
Step 5: Option B is incorrect as it focuses on intrauterine growth retardation, which is not directly related to the patient's query about birth defects.
Step 6: Option C is incorrect as a referral to high-risk obstetrics may not be necessary solely based on the patient's
A pregnant patient at 36 weeks gestation reports sudden swelling of the face and hands. What is the nurse's priority action?
A. Monitor the patient's blood pressure and check for signs of preeclampsia.
B. Instruct the patient to rest and elevate her feet.
C. Recommend the patient drink more water to reduce swelling.
D. Administer diuretics as prescribed to manage fluid retention.
Correct answer:
The correct answer is A: Monitor the patient's blood pressure and check for signs of preeclampsia. At 36 weeks gestation, sudden swelling of the face and hands can indicate preeclampsia, a serious condition characterized by high blood pressure and proteinuria in pregnancy. Monitoring blood pressure and assessing for other signs of preeclampsia, such as headache or vision changes, is crucial for timely diagnosis and intervention to prevent complications for both the mother and baby.
Summary:
B: Instructing the patient to rest and elevate her feet may provide some relief for swelling but does not address the underlying potential issue of preeclampsia.
C: Recommending increased water intake may not be appropriate if the swelling is due to preeclampsia and can worsen the condition.
D: Administering diuretics without proper assessment and diagnosis of preeclampsia can be harmful and is not the initial priority action.
It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over- the-counter analgesic, and this results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?
A. Tension
B. Migraine
C. Cluster
D. Analgesic rebound
Correct answer:
The description of the headache as starting a few hours ago, associated with nausea, sensitivity to light, and being severe in intensity suggests a migraine headache. Migraine headaches are often accompanied by these symptoms, known as migraine features. The fact that the patient experiences headaches like this less than once a week and typically uses over-the-counter analgesics to relieve them is also suggestive of migraines. Tension headaches typically present as a more mild to moderate, band-like pressure around the head, without the associated symptoms of nausea and sensitivity to light. Cluster headaches are characterized by excruciating pain around one eye, often accompanied by other symptoms like redness or tearing in the eye. Analgesic rebound headaches occur due to overuse of pain medications and typically present as daily headaches that improve with the same medication that caused them in the first place.
A patient who was diagnosed with Parkinsons disease several months ago recently began treatment with levodopa-carbidopa. The patient and his family are excited that he has experienced significant symptom relief. The nurse should be aware of what implication of the patients medication regimen?
A. The patient is in a honeymoon period when adverse effects of levodopa-carbidopa are not yet evident.
B. Benefits of levodopa-carbidopa do not peak until 6 to 9 months after the initiation of treatment.
C. The patients temporary improvement in status is likely unrelated to levodopa-carbidopa.
D. Benefits of levodopa-carbidopa often diminish after 1 or 2 years of treatment.
Correct answer:
The correct answer is A. The patient is in a honeymoon period when adverse effects of levodopa-carbidopa are not yet evident. This is because the initial response to levodopa-carbidopa in Parkinson's disease can be very positive, leading to significant symptom relief. However, over time, as the disease progresses and the body adjusts to the medication, adverse effects such as dyskinesias may become more prominent.
Choice B is incorrect because the benefits of levodopa-carbidopa can be seen relatively soon after initiation of treatment and do not necessarily take 6 to 9 months to peak. Choice C is incorrect as the temporary improvement is likely related to the medication, given the significant symptom relief experienced. Choice D is incorrect because while benefits may diminish over time, it is not necessarily after 1 or 2 years of treatment, and some patients may continue to benefit from the medication long-term.
What shortens the sarcomere during muscle contraction?
A. The binding of acetylcholine at the neuromuscular junction
B. The myosin heads binding to actin filaments and pulling them toward the center of the A-band
C. The release of calcium ions from the sarcoplasmic reticulum
D. The breakdown of ATP by the sarcoplasmic reticulum
Correct answer:
Sarcomere shortening, the basis of muscle contraction, occurs via the sliding filament mechanism. Myosin heads, protruding from thick filaments, bind to actin on thin filaments, forming cross-bridges. Using ATP-derived energy, these heads execute a power stroke, pulling actin toward the sarcomere's center specifically the A band's midpoint reducing the distance between Z lines and shortening the sarcomere. Acetylcholine initiates this by triggering an action potential, but it's not the direct shortening mechanism. Calcium release from the sarcoplasmic reticulum enables myosin-actin binding by shifting tropomyosin, a crucial step but not the act of shortening. ATP breakdown powers the process, yet the sarcoplasmic reticulum stores calcium, not hydrolyzes ATP for shortening. The myosin-actin interaction is the mechanical driver, making it the precise answer, central to muscle movement and the sliding filament theory.
Which of the following can be an effective way to prevent unintended weight loss?
A. Promoting independence by insisting residents feed themselves without help
B. Serving favorite foods
C. Telling the resident when a meal looks unappetizing
D. Insisting that residents eat everything on their trays no matter what
Correct answer:
The correct answer is B: Serving favorite foods. This is an effective way to prevent unintended weight loss because it increases the likelihood that the resident will enjoy and consume their meals. By serving favorite foods, the resident is more likely to have an appetite and eat enough to maintain their weight. This approach respects the resident's preferences and promotes a positive dining experience.
A: Promoting independence by insisting residents feed themselves without help may not be effective if the resident has difficulty feeding themselves, leading to inadequate food intake.
C: Telling the resident when a meal looks unappetizing may discourage the resident from eating, resulting in unintended weight loss.
D: Insisting that residents eat everything on their trays no matter what can be counterproductive as it may lead to stress or resistance during mealtimes, potentially causing decreased food intake.
Virgie with a positive Mantoux test result will be sent for a chest X-ray. The nurse is aware that which of the following reasons this is done?
A. To confirm the diagnosis
B. To determine if a repeat skin test is needed
C. To determine the extent of lesions
D. To determine if this is a primary or secondary infection
Correct answer:
The correct answer is C: To determine the extent of lesions. A chest X-ray is done to evaluate the presence and extent of lesions in the lungs, which helps in assessing the severity of tuberculosis infection. This is important for determining the appropriate treatment plan and monitoring the progression of the disease.
Incorrect answers:
A: To confirm the diagnosis - Chest X-ray alone cannot confirm the diagnosis of tuberculosis, as other tests such as sputum culture or PCR are needed.
B: To determine if a repeat skin test is needed - Chest X-ray is not used to determine the need for a repeat skin test, as the decision for repeat testing is based on clinical judgment and guidelines.
D: To determine if this is a primary or secondary infection - Chest X-ray may provide some information, but the distinction between primary and secondary infection is usually based on clinical history and other diagnostic tests.
RN exams clinical judgment practice questions, set 64 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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