RN exams clinical judgment practice questions, set 94
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 94
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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
Which of the following statements about mental health assessment is true?
A. The mental health assessment diagnoses specific psychiatric disorders.
B. Mental disorders occur in response to everyday life stressors.
C. Mental status is inferred through assessment of an individual's behaviours.
D. Mental health can be assessed directly, just like the characteristics of any other body system (e.g., cardiac and breath sounds).
Show answer and rationale
Correct answer: C — Mental status is inferred through assessment of an individual's behaviours.
The correct answer is C because mental status is indeed inferred through assessment of an individual's behaviors. Mental health assessment involves observing and evaluating a person's thoughts, emotions, behaviors, and overall mental functioning to determine their mental status. This includes assessing speech, mood, cognition, and perception. Choices A, B, and D are incorrect because:
A: Mental health assessment does not solely focus on diagnosing specific psychiatric disorders; it is a broader evaluation of an individual's mental well-being.
B: Mental disorders can result from a variety of factors beyond everyday life stressors, such as genetic predisposition or traumatic experiences.
D: Mental health assessment is more complex than assessing physical characteristics and involves subjective interpretation of behaviors rather than direct observation like physical assessments.
Question 2
To establish a diagnosis of shock, which is true?
A. "Systolic blood pressure must be below 90mmHg"
B. "The presence of a closed head injury should be excluded"
C. "Clinical evidence of inadequate organ perfusion must be present"
D. "The patient must fail to respond to intravenous fluid infusion"
Show answer and rationale
Correct answer: C — "Clinical evidence of inadequate organ perfusion must be present"
Step 1: Establishing a diagnosis of shock involves assessing for clinical evidence of inadequate organ perfusion, such as altered mental status, tachycardia, and cool clammy skin.
Step 2: This clinical evidence is crucial as it indicates the body's organs are not receiving enough oxygen and nutrients due to poor perfusion.
Step 3: Identifying inadequate organ perfusion helps differentiate shock from other conditions with similar symptoms.
Step 4: The other choices are incorrect because systolic blood pressure alone is not sufficient for diagnosing shock (A), closed head injury is not a defining feature of shock (B), and response to fluid infusion is important but not the sole criterion (D).
Summary: Choice C is correct as it focuses on the key clinical feature of inadequate organ perfusion, while the other choices either focus on single parameters or unrelated conditions.
Question 3
A patient preparing for surgery has moderate anxiety and is unable to understand preoperative information. Which nursing intervention is most appropriate?
A. Reassure the patient that all nurses are skilled in providing postoperative care.
B. Present the information again in a calm manner using simple language.
C. Tell the patient that staff is prepared to promote recovery.
D. Encourage the patient to express feelings to family.
Show answer and rationale
Correct answer: B — Present the information again in a calm manner using simple language.
The correct answer is B because presenting the information again in a calm manner using simple language is the most appropriate nursing intervention for a patient with moderate anxiety who is unable to understand preoperative information. This approach helps to address the patient's anxiety by providing clear and concise information in a way that is easier for them to comprehend. Reassuring the patient about postoperative care (choice A) does not directly address the patient's current state of anxiety and lack of understanding. Telling the patient that staff is prepared to promote recovery (choice C) does not provide the necessary information for the patient to understand the upcoming surgery. Encouraging the patient to express feelings to family (choice D) may be beneficial but does not address the main issue of the patient's inability to understand preoperative information.
Question 4
Surgical induction of labor refers to the use of
A. Cytotec and mechanical cervical dilatation
B. Sweeping of membranes and amniotomy
C. Mechanical cervical dilatation and buscopan
D. Artificial rupture of membranes and syntocinon
Show answer and rationale
Correct answer: B — Sweeping of membranes and amniotomy
The correct answer is B: Sweeping of membranes and amniotomy.
1. Sweeping of membranes involves manually separating the amniotic sac from the lower part of the uterus, stimulating the release of prostaglandins to induce labor.
2. Amniotomy is the artificial rupture of membranes, which can accelerate labor by releasing amniotic fluid and initiating contractions.
3. These methods are commonly used for surgical induction of labor due to their effectiveness and minimal invasiveness compared to other options.
Incorrect choices:
A: Cytotec is a medication used for labor induction, but mechanical cervical dilatation is not a standard surgical method.
C: Buscopan is used for relaxation of smooth muscle and not commonly used for labor induction.
D: Syntocinon is a synthetic form of oxytocin used to induce or augment labor, but it is not typically used in surgical induction methods.
Question 5
A client has been given a diagnosis of human immunodeficiency virus (HIV). Which statement made by the client does the nurse recognize as the bargaining stage of grief?
A. I hate my partner for giving me this disease I will die from!Â
B. If I don't do intravenous (IV) drugs anymore, God won't let me die.Â
C. I am going to support groups and learn more about the disease.Â
D. Can you please re-draw the test results, I think they may be wrong?Â
Show answer and rationale
Correct answer: B — If I don't do intravenous (IV) drugs anymore, God won't let me die.Â
The correct answer is B because it reflects the bargaining stage of grief in the context of the HIV diagnosis. In this stage, the individual tries to negotiate with a higher power or fate to avoid the reality of the situation. By stating, "If I don't do intravenous drugs anymore, God won't let me die," the client is demonstrating an attempt to make a deal with a higher power to avoid the consequences of the diagnosis. This statement shows an element of bargaining and denial.
Choices A, C, and D do not represent the bargaining stage of grief. Choice A expresses anger towards the partner, which aligns more with the anger stage of grief. Choice C demonstrates acceptance and a proactive approach to learning about the disease, indicating a stage beyond bargaining. Choice D reflects denial, as the client is requesting to redo the test results instead of accepting the diagnosis.
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Question 6
On the 15-th day after a minor trauma of the right foot a patient felt malaise, fatigability, irritability, headache, high body temperature, feeling of compression, tension and muscular twitching of his right crus. What disease can it be?
A. Tetanus
B. Anaerobic gas gangrene
C. Erysipelas
D. Acute thrombophlebitis
Correct answer:
The correct answer is A: Tetanus. Tetanus is caused by the bacterium Clostridium tetani, which produces a toxin affecting the nervous system. Symptoms such as malaise, irritability, muscular twitching, and high body temperature are characteristic of tetanus due to muscle spasms and rigidity. The 15-day incubation period after trauma aligns with the typical onset of tetanus symptoms.
Incorrect choices:
B: Anaerobic gas gangrene - This condition usually presents with localized tissue necrosis and gas bubbles in the affected area, not systemic symptoms like malaise and headache.
C: Erysipelas - This is a bacterial skin infection presenting with red, swollen patches, not the neurological symptoms seen in tetanus.
D: Acute thrombophlebitis - This is a blood clot in a vein causing pain and swelling, not associated with the systemic symptoms and muscle twitching seen in tetanus.
A patient with schizophrenia has been stabilized in the Crisis Center and is about to be discharged. He will be living with his family, but the family knows nothing about the patient's illness, its treatment, or the role they can play in his recovery. Which activity would be most beneficial for the family to attend?
A. Psychoanalytic group
B. Psychoeducational group
C. Individual counseling
D. Family therapy
Correct answer:
The correct answer is B: Psychoeducational group. This option is most beneficial as it will provide the family with education about schizophrenia, its treatment, and the role they can play in the patient's recovery. This will help the family better understand the illness, how to support the patient, and how to communicate effectively.
Explanation:
1. Psychoanalytic group (A) focuses on exploring unconscious thoughts and emotions, which may not be as practical or helpful for educating the family about schizophrenia.
2. Individual counseling (C) may not involve the family as a whole and may not provide the necessary education and support for the family unit.
3. Family therapy (D) could be beneficial, but psychoeducational group specifically targets providing knowledge and skills needed to support the patient's recovery, making it the most appropriate choice in this scenario.
A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply
A. Position the client flat for at least 3 hrs or as directed by the physician
B. Encourage a liberal fluid intake
C. Keep the room well lit and play some soothing music in the ground
D. Help the client ambulate and perform a few light leg exercises#
Correct answer:
The correct answer is A: Position the client flat for at least 3 hrs or as directed by the physician.
Rationale:
1. Positioning the client flat helps prevent post-lumbar puncture headache by allowing the CSF to replenish and stabilize the pressure in the spinal canal.
2. The recommended time frame of 3 hours allows for adequate CSF reabsorption and reduces the likelihood of headache.
3. Following physician's direction is crucial to individualize care based on the specific situation.
Summary of other choices:
B: Encouraging fluid intake is generally good practice but may not directly alleviate post-lumbar puncture headache.
C: Keeping the room well lit and playing soothing music may not address the physiological cause of the client's symptoms.
D: Ambulation and leg exercises are not recommended immediately post-lumbar puncture as they may exacerbate dizziness and headache.
A nurse is caring for an adolescent who has experienced abuse and neglect since early childhood. The nurse should understand that this is an example of which of the following types of trauma?
A. Vicarious trauma
B. Acute trauma
C. Chronic trauma
D. Historical trauma
Correct answer:
Step 1: Chronic trauma refers to repeated exposure to traumatic events over a prolonged period, such as ongoing abuse and neglect in this case.
Step 2: The adolescent has experienced abuse and neglect since early childhood, indicating a long-term and persistent traumatic experience.
Step 3: Vicarious trauma involves indirect exposure to trauma through witnessing or hearing about others' experiences.
Step 4: Acute trauma refers to a single traumatic event with immediate impact, not a prolonged pattern like chronic trauma.
Step 5: Historical trauma relates to collective trauma experienced by a group over generations, not an individual's ongoing abuse and neglect.
Summary: Choice C is correct because it best describes the repeated and prolonged nature of the adolescent's traumatic experiences, while the other choices do not align with the specific circumstances presented.
A 65-year-old patient with fever and a productive cough had a sputum sample revealing Gram-negative, non-motile, rod-shaped bacteria. What is the most likely causative agent?
A. Klebsiella pneumoniae
B. Pseudomonas aeruginosa
C. Escherichia coli
D. Haemophilus influenzae
Correct answer:
The correct answer is A: Klebsiella pneumoniae. This bacterium is commonly associated with pneumonia in elderly patients. Klebsiella pneumoniae is a Gram-negative, non-motile, rod-shaped bacterium that frequently causes pneumonia in individuals with underlying health conditions. It is known for its ability to produce a distinctive mucoid capsule. Pseudomonas aeruginosa (B) is more commonly associated with hospital-acquired infections, particularly in immunocompromised individuals. Escherichia coli (C) is a common cause of urinary tract infections but is less likely in this case due to the symptoms and sputum sample results. Haemophilus influenzae (D) is another common respiratory pathogen, but in this scenario, Klebsiella pneumoniae is the most likely causative agent based on the patient's age, symptoms, and the characteristics of the bacteria described in the sputum sample.
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:
The correct answer is B because having a plausible explanation of how the new MCP could cause harm is essential to confidently present concerns to administration. This step involves understanding the potential mechanisms by which the MCP may be causing issues, providing a logical basis for the observed problems. Without a clear explanation, it would be challenging to convince administration of the causal link.
Choices A, C, and D are incorrect:
A: Merely having certain conditions present doesn't provide a solid foundation for presenting concerns without a plausible explanation.
C: Relying solely on feelings without concrete evidence or reasoning is not sufficient to support the claim.
D: While consistently seeing mouth inflammation is concerning, without understanding how the MCP could be causing it, it lacks a logical basis for presenting the issue to administration.
A nursing diagnosis for a patient with bulimia nervosa is Ineffective coping related to feelings of loneliness and isolation, as evidenced by use of overeating and self-induced vomiting to comfort self. Select the best outcome related to this diagnosis. Within 2 weeks, the patient will:
A. appropriately express angry feelings.
B. verbalize two positive things about self.
C. verbalize the importance of eating a balanced diet.
D. identify two alternative methods of coping with loneliness and isolation.
Correct answer:
The correct answer is D because it directly addresses the nursing diagnosis of ineffective coping related to feelings of loneliness and isolation. By identifying two alternative methods of coping, the patient can develop healthier strategies to manage these emotions instead of resorting to overeating and vomiting. This outcome promotes long-term behavioral change and helps the patient build resilience.
Choice A is incorrect because expressing angry feelings may not necessarily address the underlying issues of loneliness and isolation. Choice B is incorrect as verbalizing positive things about oneself may be beneficial but does not directly address coping mechanisms for loneliness and isolation. Choice C is also incorrect because understanding the importance of a balanced diet does not directly address coping strategies for managing emotions like loneliness and isolation.
Using the UNICEF Socio-Ecological Model, which statement is an example of a community health center working at the organizational level to promote health care?
A. Teaching a client how to self-administer insulin injections
B. Assisting a new mother with breastfeeding
C. Treating all clients regardless of their ability to pay
D. Lobbying to ensure health care for transgender clients
Correct answer:
The correct answer is C because treating all clients regardless of their ability to pay aligns with the organizational level of the UNICEF Socio-Ecological Model. This demonstrates a commitment to providing equitable access to healthcare services within the community health center. By offering care regardless of financial resources, the center addresses social determinants of health, promotes health equity, and contributes to overall community well-being.
Choice A, teaching a client to self-administer insulin injections, is an example of an individual-level intervention. Choice B, assisting a new mother with breastfeeding, is a behavioral-level intervention. Choice D, lobbying for health care for transgender clients, pertains to policy-level advocacy. These choices do not directly address organizational-level efforts to promote health care within a community health center.
The nurses in a labor and delivery unit are concerned about the high incidence of cesarean deliveries at their facility and initiate an internal study. Which is the most likely condition the nurses will recognize as a contributor to the rate of cesarean births?
A. The facility has a high rating for managing high-risk pregnancies.
B. Policies and parameters for cesarean need to be reviewed and refined.
C. Community education about the advantages of vaginal birth is deficient.
D. The incidence of maternal requests for cesarean delivery is increasing.
Correct answer:
Step 1: Maternal requests for cesarean delivery are a significant contributor to the high incidence of cesarean births.
Step 2: Maternal requests may stem from various factors such as fear of labor pain, convenience, or personal preferences.
Step 3: Nurses can address this issue by educating women on the risks and benefits of cesarean versus vaginal delivery.
Step 4: By understanding and addressing maternal requests, the facility can potentially lower the cesarean delivery rate.
Summary:
- Choice A is incorrect as high-risk pregnancies do not directly contribute to the rate of cesarean births.
- Choice B is incorrect as reviewing cesarean policies alone may not address the underlying issue of maternal requests.
- Choice C is incorrect as community education, while important, may not directly impact the rate of cesarean deliveries as compared to addressing maternal requests.
The nurse is auscultating the fetal heart rate (FHR) on a patient at 37 weeks’ gestation. The nurse notes a line of darkened pigmentation on the pregnant person’s abdomen starting at the symphysis pubis and ending at the sternum. How does the nurse document this finding?
A. cholasma
B. linea nigra
C. spider nevi
D. striae gravidarum
Correct answer:
The correct answer is B: linea nigra. The linea nigra is a darkened pigmented line that runs from the symphysis pubis to the sternum in pregnant individuals. This line is a normal finding in pregnancy due to hormonal changes. It is important for the nurse to document this finding accurately as it is a common physiological change.
Rationale:
1. Cholasma (A) is also known as the mask of pregnancy, presenting as dark patches on the face.
2. Spider nevi (C) are small, dilated blood vessels on the skin, not related to the linea nigra.
3. Striae gravidarum (D) are stretch marks that occur due to rapid stretching of the skin during pregnancy, not related to the pigmented line.
In summary, the correct answer is B because the darkened line described is characteristic of linea nigra, a common finding in pregnancy, while the other choices are unrelated to this specific observation.
RN exams clinical judgment practice questions, set 94 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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