Clinical Judgment Practice 2 -RN 3.0
Test Questions And 100% Correct
Answers.
A nurse is caring for a client in a clinic.
Exhibit 1
Nurses NotesFirst visit:Weight 77.3 kg (175.1 lb) Client presented to the clinic and reports
frequent headaches, stomach cramps, and diarrhea. Client reports issues with marriage but is
attending counseling with spouse. Education given on new prescription citalopram.One month
later:Weight: 71.1 kg (156.5 lb)Client presents to the clinic for follow up. Client reports
continued headache, stomach cramps, and diarrhea. Client states that it is difficult to take
citalopram medication daily. Client reports that their relationship has failed. Client states, "I am
so sad and lonely. I never thought I would have to endure such pain. I don't know how I am
going to go on."
The nurse should first evaluate the client's (blank) as evidenced by the client's (blank) - Answer
Risk for harming themselves, report of hopelessness
When prioritizing hypotheses, the nurse should evaluate the risk for the client to harm
themselves due to the client's report of hopelessness. Risk for suicide is increased when
depression is accompanied with a loss, feelings of hopelessness, and a history of suicide
attempts. A client who has suicidal ideations and a plan to harm themselves is an emergency
and the nurse should intervene immediately.
A nurse on a medical surgical floor is caring for a newly admitted client following a motor
vehicle crash.
Exhibit 1
Exhibit 2
Exhibit 3
Exhibit 4
History and PhysicalDay 1:Client is hospitalized following a motor vehicle crash.Client lost
consciousness for approximately 30 min following the crash. Client is not oriented to place or
time. Follows commands.Multiple bruises noted on client's upper and lower extremities,
petechia noted on lower legs.Client reports pain as a 2 on a 0 to 10 scale 30 min following oral
pain medication.Day 2:Client is oriented to place and time. Client has slurred speech, poor
coordination, and impaired thinking.Client reports nausea, vomiting, and appears
agitated.Client is diaphoretic. Client reports pain as a 4 on a 0 to 10 scale.
Which actions should the nurse take? - Answer Implement seizure precautions, delegate AP
in the room, offer orange juice, Rx for lorazepam, report behavior to provider, assess Hx of
alcohol use
, When taking action, the nurse should implement seizure precautions for a client who is
experiencing withdrawals from alcohol because of the risk for seizures and alcohol withdrawal
delirium. Withdrawal seizures can occur 12 to 24 hr after the cessation of alcohol. The nurse
should assess the client's history of alcohol use because the client is exhibiting manifestations of
alcohol withdrawal such as vital sign changes, agitation, nausea, and vomiting. The nurse should
delegate for an AP to stay with the client to orient the client to reality if needed and to assist in
keeping the client calm. The nurse should report the client's change in behavior to the provider
to obtain the needed prescriptions to effectively care and treat the client. The nurse should
offer orange juice or other sources of carbohydrates to prevent hypoglycemia because alcohol
depletes the liver glucagon stores. The nurse should request a prescription for lorazepam to
assist the client to relax and promote sleep to prevent peripheral vascular collapse.
A nurse is caring for a child in a prenatal clinic.
Nurses Notes 28 weeks of gestation:The client reports they can feel the baby kick every hour.
The client also reports that they get a headache about weekly. 30 weeks of gestation:The client
reports an increase in headaches mostly relieved from acetaminophen.
History and Physical28 weeks of gestation:Fundal height 28 cm80.5 kg (177 lb)Deep tendon
reflexes 2+Negative clonusNo edema noted30 weeks of gestation:Fundal height 31 cm81.4 kg
(179 lb) Deep tendon reflexes 2+Negative clonus1+ pitting pedal edemaSwelling of the hands
Diagnostic Results28 weeks of gestation: Proteinuria negative30 weeks of gestation:Reactive
nonstress test (NST) Proteinuria trace
The client is at risk for developing (blank) due to (blank) - Answer preeclampsia, blood
pressure
When analyzing cues, the nurse should note that gestational hypertension is a systolic blood
pressure greater than 140 mm Hg or a diastolic blood pressure greater than 90 mm Hg for two
occasions. Approximately 25% to 50% of client's who have gestational hypertension will develop
preeclampsia. The nurse should monitor this client for clinical manifestations of preeclampsia,
such as proteinuria greater or equal to 1 plus, hyperactive reflexes, visual disturbances, severe
headaches, and right upper quadrant abdominal pain.
A nurse is caring for an infant in a clinic.
Nurses' Notes4 months old:Weight 6.8 kg (15 lb)Height 63 cm (24.8 in)Developmental
milestones: slight head lag when pulled into a sitting position, can hold a rattle in one hand but
unable to pick it up when it drops, makes consonant sounds "n" and "k"6 months old:Weight 8
kg (17.6 lb)Height 67cm (26.4 in)Developmental milestones: almost no head lag when pulled
into a sitting position, drops a cube when another one is offered, makes consonant sounds "n, k,
g, and b"
The nurse should follow up on (blank) and (blank) - Answer gross motor skills, verbal skills
When recognizing cues, the nurse should follow up on the infant's gross motor developmental
skills and the infant's verbal skills. At 6 months of age, the infant should be able to sit with a
straight back and have no head lag when pulling into a sitting position. The infant should also be
Test Questions And 100% Correct
Answers.
A nurse is caring for a client in a clinic.
Exhibit 1
Nurses NotesFirst visit:Weight 77.3 kg (175.1 lb) Client presented to the clinic and reports
frequent headaches, stomach cramps, and diarrhea. Client reports issues with marriage but is
attending counseling with spouse. Education given on new prescription citalopram.One month
later:Weight: 71.1 kg (156.5 lb)Client presents to the clinic for follow up. Client reports
continued headache, stomach cramps, and diarrhea. Client states that it is difficult to take
citalopram medication daily. Client reports that their relationship has failed. Client states, "I am
so sad and lonely. I never thought I would have to endure such pain. I don't know how I am
going to go on."
The nurse should first evaluate the client's (blank) as evidenced by the client's (blank) - Answer
Risk for harming themselves, report of hopelessness
When prioritizing hypotheses, the nurse should evaluate the risk for the client to harm
themselves due to the client's report of hopelessness. Risk for suicide is increased when
depression is accompanied with a loss, feelings of hopelessness, and a history of suicide
attempts. A client who has suicidal ideations and a plan to harm themselves is an emergency
and the nurse should intervene immediately.
A nurse on a medical surgical floor is caring for a newly admitted client following a motor
vehicle crash.
Exhibit 1
Exhibit 2
Exhibit 3
Exhibit 4
History and PhysicalDay 1:Client is hospitalized following a motor vehicle crash.Client lost
consciousness for approximately 30 min following the crash. Client is not oriented to place or
time. Follows commands.Multiple bruises noted on client's upper and lower extremities,
petechia noted on lower legs.Client reports pain as a 2 on a 0 to 10 scale 30 min following oral
pain medication.Day 2:Client is oriented to place and time. Client has slurred speech, poor
coordination, and impaired thinking.Client reports nausea, vomiting, and appears
agitated.Client is diaphoretic. Client reports pain as a 4 on a 0 to 10 scale.
Which actions should the nurse take? - Answer Implement seizure precautions, delegate AP
in the room, offer orange juice, Rx for lorazepam, report behavior to provider, assess Hx of
alcohol use
, When taking action, the nurse should implement seizure precautions for a client who is
experiencing withdrawals from alcohol because of the risk for seizures and alcohol withdrawal
delirium. Withdrawal seizures can occur 12 to 24 hr after the cessation of alcohol. The nurse
should assess the client's history of alcohol use because the client is exhibiting manifestations of
alcohol withdrawal such as vital sign changes, agitation, nausea, and vomiting. The nurse should
delegate for an AP to stay with the client to orient the client to reality if needed and to assist in
keeping the client calm. The nurse should report the client's change in behavior to the provider
to obtain the needed prescriptions to effectively care and treat the client. The nurse should
offer orange juice or other sources of carbohydrates to prevent hypoglycemia because alcohol
depletes the liver glucagon stores. The nurse should request a prescription for lorazepam to
assist the client to relax and promote sleep to prevent peripheral vascular collapse.
A nurse is caring for a child in a prenatal clinic.
Nurses Notes 28 weeks of gestation:The client reports they can feel the baby kick every hour.
The client also reports that they get a headache about weekly. 30 weeks of gestation:The client
reports an increase in headaches mostly relieved from acetaminophen.
History and Physical28 weeks of gestation:Fundal height 28 cm80.5 kg (177 lb)Deep tendon
reflexes 2+Negative clonusNo edema noted30 weeks of gestation:Fundal height 31 cm81.4 kg
(179 lb) Deep tendon reflexes 2+Negative clonus1+ pitting pedal edemaSwelling of the hands
Diagnostic Results28 weeks of gestation: Proteinuria negative30 weeks of gestation:Reactive
nonstress test (NST) Proteinuria trace
The client is at risk for developing (blank) due to (blank) - Answer preeclampsia, blood
pressure
When analyzing cues, the nurse should note that gestational hypertension is a systolic blood
pressure greater than 140 mm Hg or a diastolic blood pressure greater than 90 mm Hg for two
occasions. Approximately 25% to 50% of client's who have gestational hypertension will develop
preeclampsia. The nurse should monitor this client for clinical manifestations of preeclampsia,
such as proteinuria greater or equal to 1 plus, hyperactive reflexes, visual disturbances, severe
headaches, and right upper quadrant abdominal pain.
A nurse is caring for an infant in a clinic.
Nurses' Notes4 months old:Weight 6.8 kg (15 lb)Height 63 cm (24.8 in)Developmental
milestones: slight head lag when pulled into a sitting position, can hold a rattle in one hand but
unable to pick it up when it drops, makes consonant sounds "n" and "k"6 months old:Weight 8
kg (17.6 lb)Height 67cm (26.4 in)Developmental milestones: almost no head lag when pulled
into a sitting position, drops a cube when another one is offered, makes consonant sounds "n, k,
g, and b"
The nurse should follow up on (blank) and (blank) - Answer gross motor skills, verbal skills
When recognizing cues, the nurse should follow up on the infant's gross motor developmental
skills and the infant's verbal skills. At 6 months of age, the infant should be able to sit with a
straight back and have no head lag when pulling into a sitting position. The infant should also be
