RN exams clinical judgment practice questions, set 73
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 73
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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
A nurse is caring for a patient diagnosed with bulimia nervosa. The patient states, 'I feel so ashamed after I eat.' What is the most appropriate response by the nurse?
A. You need to stop purging and focus on eating healthy foods.
B. I understand that you feel ashamed, but we are here to help you.
C. Don't worry about your eating habits. Focus on eating more regularly.
D. You need to accept your eating habits and learn to control them.
Show answer and rationale
Correct answer: B — I understand that you feel ashamed, but we are here to help you.
Correct Answer: B
Rationale:
1. Empathy: By acknowledging the patient's feelings of shame, the nurse validates their emotions and shows understanding.
2. Therapeutic Communication: Expressing empathy creates a supportive environment and encourages the patient to open up about their struggles.
3. Building Trust: Acknowledging the patient's emotions helps in building a trusting nurse-patient relationship, essential for effective care.
4. Encouraging Help-Seeking Behavior: By stating "we are here to help you," the nurse encourages the patient to seek assistance and engage in treatment.
Summary:
A: This response oversimplifies the issue and doesn't address the patient's emotional needs.
C: Ignoring the patient's feelings and focusing solely on eating habits may be counterproductive.
D: This response lacks empathy and fails to provide the necessary support for the patient's emotional well-being.
Question 2
Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this best describe?
A. Spontaneous pneumothorax
B. Chronic obstructive pulmonary disease (COPD)
C. Asthma
D. Pneumonia
Show answer and rationale
Correct answer: C — Asthma
The symptoms described, including decreased air movement, high-pitched whistling (wheezing) on expiration in all lobes, and resonant lungs on percussion, are characteristic findings of asthma. Asthma is a chronic respiratory condition characterized by airway inflammation, bronchoconstriction, and increased mucus production, leading to symptoms like wheezing, shortness of breath, chest tightness, and cough. The presence of wheezing, particularly on expiration, is a classic sign of asthma. In contrast, spontaneous pneumothorax would typically present with sudden chest pain and shortness of breath, accompanied by hyperresonant percussion notes due to trapped air in the pleural space. COPD, a chronic lung condition characterized by progressive airflow limitation, would often present with symptoms such as chronic cough, sputum production, and dyspnea on exertion. Pneumonia is an infection of the lung tissue,
Question 3
A community health nurse recognizes an increase in maternal mortality in the neighborhood. What could the community health nurse do?
A. Conduct weekly prenatal appointments in their home.
B. Draw blood on all pregnant persons to look for anemia.
C. Assess the health of a baby using an ultrasound.
D. Develop an educational pamphlet discussing signs of preeclampsia.
Show answer and rationale
Correct answer: D — Develop an educational pamphlet discussing signs of preeclampsia.
The correct answer is D because developing an educational pamphlet discussing signs of preeclampsia can help raise awareness and educate pregnant individuals about a life-threatening condition contributing to maternal mortality. This intervention can empower individuals to recognize warning signs early, seek timely medical care, and potentially prevent adverse outcomes. Conducting weekly prenatal appointments in their home (Choice A) may not address the underlying causes of maternal mortality and may not be feasible for all pregnant individuals. Drawing blood on all pregnant persons to look for anemia (Choice B) may not be the most effective strategy to address maternal mortality as anemia is just one of many contributing factors. Assessing the health of a baby using an ultrasound (Choice C) does not directly address the issue of maternal mortality and focuses on fetal, rather than maternal, well-being.
Question 4
The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. Thecpatient states that she is having severe pain that had a sudden onset. What is the nurses most appropriate action?
A. Palpate the surgical site.
B. Remove the dressing to assess the surgical site.
C. Call the surgeon to report the patients pain.
D. Administer a dose of an NSAID.
Show answer and rationale
Correct answer: C — Call the surgeon to report the patients pain.
In this scenario, the patient who has had a cervical diskectomy is experiencing severe pain with a sudden onset, which can be indicative of a complication such as bleeding, infection, or nerve impingement. The nurse's most appropriate action is to call the surgeon immediately to report the patient's pain. The surgeon needs to be informed promptly so that a further assessment can be made and appropriate interventions can be initiated to address the cause of the sudden pain. Palpating the surgical site or removing the dressing without consulting the surgeon first may worsen the situation or increase the risk of complications. Administering an NSAID is not appropriate in this situation without further evaluation and guidance from the surgeon. It is essential to prioritize patient safety and ensure that the patient receives timely and appropriate care by involving the surgeon in the decision-making process.
Question 5
For a diabetic male client with a foot ulcer, the doctor orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and bedtime. Why are wet-to-dry dressings used for this client?
A. They contain exudate and provide a moist wound environment.
B. They protect the wound from mechanical trauma and promote healing.
C. They debride the wound and promote healing by secondary intention.
D. They prevent the entrance of microorganisms and minimize wound discomfort.
Show answer and rationale
Correct answer: C — They debride the wound and promote healing by secondary intention.
The correct answer is C because wet-to-dry dressings are used to debride the wound by removing necrotic tissue and promoting healing by secondary intention. Here's the rationale:
1. Wet-to-dry dressings involve moistening the gauze dressing with saline solution before placing it on the wound.
2. As the dressing dries, it adheres to the wound bed and necrotic tissue, helping to remove it during dressing changes.
3. This debridement process helps in promoting healing by allowing healthy tissue to grow and fill in the wound.
4. The wet-to-dry dressing method is specifically indicated for wounds with necrotic tissue, like foot ulcers in diabetic clients.
In summary, the other choices are incorrect because A focuses on maintaining a moist environment, B on protecting the wound, and D on preventing infection and minimizing discomfort, which are not the primary purposes of wet-to-dry dressings in this context.
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Question 6
A mother conveys concern over the fact that she is not certain if her newborn is receiving enough nutrients from breastfeeding. This is the baby's first clinic visit after birth. What information can you provide that will help alleviate her fears regarding nutrient status for her newborn?
A. Monitor the infant's output; as long as at least six or more diapers are changed in a 24-hour period, the baby is receiving sufficient intake.
B. Tell the mother that if a baby is satisfied with feeding, she or he will be content and not fussy.
C. Tell the mother that breast milk contains everything required for the infant and not to worry about nutrition.
D. Provide nutrition information in the form of pamphlets for the mother to take home with her so that she uses them as a point of reference.
Correct answer:
Step 1: Monitoring the infant's output through diaper changes is a reliable indicator of sufficient nutrient intake.
Step 2: Six or more diapers changed in a 24-hour period signifies that the baby is getting enough nutrients from breastfeeding.
Step 3: This method is practical and easy for the mother to observe and track regularly.
Step 4: It reassures the mother that her newborn is receiving adequate nutrition, addressing her concerns effectively.
Summary:
- Choice A is correct as it provides a tangible and practical method for assessing the baby's nutrient intake.
- Choice B is incorrect as satisfaction with feeding does not directly correlate with nutrient intake.
- Choice C is incorrect as it oversimplifies the situation and does not offer a practical solution.
- Choice D is incorrect as providing pamphlets may not address the mother's immediate concerns about the baby's nutrient status.
An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which documentation best indicates the treatment was successful?
A. No complaints related to sexual function; to return next week.
B. Patient reports achieving orgasm last week; seems very happy.
C. Reports satisfaction with sexual encounters; feels partner is supportive.
D. Reports achieving orgasm occasionally; relationship with partner is adequate.
Correct answer:
Step 1: Choice C indicates satisfaction with sexual encounters and feeling supported by the partner, which suggest a positive outcome in addressing the inability to achieve orgasm and concerns about the relationship.
Step 2: The patient feeling satisfied and supported signifies improvement in sexual function and relationship dynamics.
Step 3: This documentation reflects a holistic approach to addressing the patient's concerns, focusing on emotional well-being and relationship quality.
Step 4: Overall, choice C demonstrates a comprehensive resolution to the patient's initial complaints and indicates successful treatment.
Summary:
Choice C is the correct answer as it shows improvement in both sexual function and relationship satisfaction. Choices A, B, and D do not address the patient's concerns about the relationship or emotional well-being, making them less appropriate indicators of treatment success.
During the latter stages of pregnancy, many women experience an increase in body hair growth in a masculine pattern. What is the explanation for this?
A. The ovaries secrete some testosterone along with the large amounts of estrogen produced late in pregnancy
B. The fetal ovaries and testes secrete androgenic steroids
C. The maternal and fetal adrenal glands secrete large amounts of androgenic steroids that are used by the placenta to form estrogen
D. The placenta secretes large amounts of estrogen, some of which is metabolized to testosterone
Correct answer:
Step 1: Maternal and fetal adrenal glands secrete androgenic steroids.
Step 2: Placenta uses these androgenic steroids to form estrogen.
Step 3: Increased estrogen levels can lead to body hair growth.
Therefore, the correct answer (C) is supported by the process of androgenic steroids being secreted by the adrenal glands, utilized by the placenta to form estrogen, resulting in increased body hair growth.
Summary:
A (The ovaries secrete some testosterone along with estrogen) is incorrect as testosterone is not primarily secreted by the ovaries late in pregnancy.
B (The fetal ovaries and testes secrete androgenic steroids) is incorrect as the primary source of androgenic steroids in this context is the adrenal glands, not fetal ovaries or testes.
D (The placenta secretes estrogen, some of which is metabolized to testosterone) is incorrect as the main source of estrogen in this scenario is from the and
Which nursing intervention has highest priority for a patient with bulimia nervosa?
A. Assist the patient to identify triggers to binge eating.
B. Provide remedial consequences for weight loss.
C. Assess for signs of impulsive eating.
D. Explore needs for health teaching.
Correct answer:
The correct answer is A: Assist the patient to identify triggers to binge eating. The highest priority for a patient with bulimia nervosa is addressing the root cause of the behavior, which is often triggered by emotional or situational factors. By identifying triggers, the patient can learn to recognize and manage them effectively, ultimately reducing the frequency of binge eating episodes. This intervention focuses on addressing the underlying issue and promoting long-term recovery.
Summary:
B: Providing remedial consequences for weight loss is not the priority as the main concern is addressing the binge eating behavior.
C: Assessing for signs of impulsive eating is important, but identifying triggers takes precedence in addressing the behavior.
D: Exploring needs for health teaching may be relevant, but addressing triggers to binge eating is more immediate and crucial for managing bulimia nervosa.
The home health nurse is performing a home visit for an oncology patient discharged 3 days ago after completing treatment for non-Hodgkin lymphoma. The nurses assessment should include examination for the signs and symptoms of what complication?
A. Tumor lysis syndrome (TLS)
B. Syndrome of inappropriate antiduretic hormone (SIADH)
C. Disseminated intravascular coagulation (DIC)
D. Hypercalcemia
Correct answer:
The correct answer is A: Tumor lysis syndrome (TLS). In this scenario, the oncology patient has completed treatment for non-Hodgkin lymphoma. TLS is a potential complication post-treatment due to the rapid breakdown of cancer cells, leading to release of intracellular contents like potassium, phosphorus, and uric acid into the bloodstream. This can result in electrolyte imbalances, renal failure, and cardiac arrhythmias. The nurse should assess for signs such as hyperkalemia, hyperphosphatemia, hypocalcemia, and elevated uric acid levels. Monitoring renal function and fluid status is crucial.
Summary of other choices:
B: Syndrome of inappropriate ADH (SIADH) is characterized by excessive release of antidiuretic hormone leading to water retention and dilutional hyponatremia. Not typically associated with post-treatment complications in oncology patients.
C: Disseminated intravascular coagulation (DIC)
A nurse is providing care to an older adult client. Which of the following screening tools should the nurse use to gather data for the client?
A. The Gerontological Personality Disorder Scale (GPS)
B. Patient Health Questionnaire-9 (PHQ-9)
C. Denver II Developmental Screening
D. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
Correct answer:
The correct answer is B: Patient Health Questionnaire-9 (PHQ-9). This tool is specifically designed to screen for depression in older adults. The PHQ-9 is validated and widely used in clinical settings to assess depressive symptoms. It is essential to use a screening tool tailored to the client's age group to ensure accurate results. The other choices are incorrect because:
A: The Gerontological Personality Disorder Scale (GPS) is not a standard screening tool for older adults and focuses on personality disorders, not depression.
C: Denver II Developmental Screening is used to assess developmental milestones in children, not appropriate for older adults.
D: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is a diagnostic manual used by mental health professionals to classify mental disorders, not a screening tool for gathering data on depressive symptoms in older adults.
An older female client tells the nurse that her muscles have gradually been getting weaker. What is the best initial response by the nurse?
A. Explain that this is an expected occurrence with aging.
B. Observe the lower extremities for signs of muscle atrophy.
C. Review the medical record for recent diagnostic test results.
D. Ask the client to describe the changes that have occurred.
Correct answer:
The best initial response by the nurse when the client reports muscle weakness is to ask the client to describe the changes that have occurred. This approach allows the nurse to gain a better understanding of the client's experience, the extent of weakness, any associated symptoms, and potential triggers. By actively listening to the client's description, the nurse can gather valuable information that will aid in a comprehensive assessment and development of a tailored care plan. Choice A is incorrect because assuming muscle weakness is solely due to aging without further assessment can lead to overlooking potential underlying causes. Choice B is incorrect as observing for signs of muscle atrophy should come after gathering information directly from the client. Choice C is incorrect as reviewing diagnostic test results should not be the initial step when the client's current experience is being shared.
The nurse caring for a patient who is concerned about her 10-pound weight loss relative to her chemotherapy tells the patient, "Lucky you! Every cloud has a silver lining." The nurse's statement is an example of which type of communication block?
The correct answer is C: Using clichés. The nurse's statement, "Lucky you! Every cloud has a silver lining," is a cliché that minimizes the patient's concerns about her weight loss and chemotherapy. Clichés are overused phrases that lack originality and can be dismissive or unhelpful in communication. In this case, the nurse's response does not address the patient's emotional or physical needs and fails to provide meaningful support.
Incorrect choices:
A: Defensive response - This choice involves reacting defensively to the patient's concerns, which is not demonstrated in the nurse's statement.
B: Asking probing questions - This choice involves seeking further information from the patient, which is not reflected in the nurse's cliché response.
D: Changing the subject - This choice involves diverting the conversation away from the patient's concerns, which is not explicitly done in the given scenario.
A 25-year-old woman who works as an air traffic controller presents with facial pain and severe headache. She reports that she sometimes feels the pain in her neck or ear and that it is particularly bad during very busy times at the airport. What is the most likely diagnosis?
A. Migraine headache
B. Cluster headache
C. Temporomandibular joint syndrome
D. Sinus headache
Correct answer:
The most likely diagnosis for the 25-year-old woman who works as an air traffic controller and presents with facial pain and severe headache that sometimes radiates to her neck or ear, aggravated by stress, is Temporomandibular joint syndrome. This syndrome involves pain in the jaw joint and the muscles controlling jaw movement, which can radiate to the surrounding areas like the neck and ear. Stress and clenching of the jaw commonly exacerbate the symptoms. Migraine headache (choice A) typically presents with other symptoms like nausea, sensitivity to light or sound, and can be triggered by various factors, not just stress. Cluster headache (choice B) is characterized by severe, unilateral pain around the eye with associated autonomic symptoms. Sinus headache (choice D) is usually associated with sinus congestion or infection, presenting with facial pressure or pain, often worsened by bending forward.
The nurse cares for a client who does not follow dietary recommendations for treatment of heart failure. Which statement, if made by the nurse, demonstrates respect for the client?
A. "It doesn't make any difference to me whether you decide to eat healthy or not."
B. "You will get more attention from your physician, if you follow diet restrictions."
C. "I care about you even if you are not following your dietary restrictions."
D. "Have you noticed that patients who eat healthy foods receive better healthcare?"
Correct answer:
The correct answer is C: "I care about you even if you are not following your dietary restrictions." This statement demonstrates respect for the client by acknowledging the client's autonomy and worth as an individual, regardless of their choices. It shows empathy and compassion without judgment, promoting a supportive and non-judgmental relationship.
Explanation:
A: This statement is dismissive and indifferent, lacking empathy and respect for the client's choices.
B: This statement uses a conditional approach, linking attention from the physician to following diet restrictions, which may come off as manipulative and lacks genuine care for the client.
D: This statement uses a comparison approach, which may make the client feel judged or inadequate for not following dietary recommendations. It also implies that better healthcare is contingent on following a specific diet, which may not always be true.
RN exams clinical judgment practice questions, set 73 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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