NURS 1240 Clinical Judgement EAQ 1 NURS 1240 Clinical Judgement EAQ.pdf
NURS 1240 Clinical Judgement EAQ
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1. When evaluating fluid loss for Directly proportional
a client with burns, which re-
lationship between a client's rationale: There is greater extravasation of fluid into the tis-
burned body surface area and sues as the amount of tissue involved increases. Thus the
fluid loss would the nurse con- relationship of fluid loss to body surface area is directly
sider? proportional. Formulas (e.g., Parkland [Baxter) are used to
- Equal estimate fluid loss based on percentage of body surface area
- Unrelated burned. Equal, unrelated, and inversely related options are
- Inversely related incorrect; the relationship is proportional.
- Directly proportional
2. Which area of the client's body Sacrum
would the nurse consider a
high risk for developing a pres- rationale: The sacrum is the center of the greatest body mass;
sure injury when caring for an elevated torso exerts pressure toward this area.
an older adult with Alzheimer Although the scapulae are at risk, they do not bear the great-
type dementia who consistently est body weight as when the client is in the semi-Fowler
sleeps in a semi-Fowler position position. The ischial spine bears the greatest pressure when
in bed? the client is in an upright sitting position.
- Sacrum Greater trochanter is at risk when the client is in a side-lying
- Scapulae position.
- Ischial spine
- Greater trochanter
3. Which condition is contraindi- Dementia
cated for St. John's wort herbal
therapy? rationale: St. John's wort is contraindicated for dementia; this
- Anxiety herbal therapy is used to treat anxiety. Bupropion therapy is
- Seizures contraindicated for seizures. Valerian (Valeriana officinalis) is
- Dementia contraindicated for cardiac disease.
- Cardiac disease
Page 1 of 19 1 of 19 Page 1
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4. Which condition contraindi- Pregnancy
cates the use of ginseng herbal
therapy? rationale: Pregnancy is contraindicated for ginseng herbal
- Pregnancy therapy. Schizophrenia, bipolar depression, and Alzheimer
- Schizophrenia disease are contraindicated for St. John's Wort herbal therapy.
- Bipolar depression
- Alzheimer disease
5. Which toxic effect would the Circulatory collapse
nurse find in a client who has
overdosed on isocarboxazid? rationale: The clinical symptoms of monoamine oxidase in-
- Mydriasis hibitors (MAOls) generally appear after 12 hours of inges-
- Bradycardia tion.
- Hypothermia Circulatory collapse is associated with MAOI toxicity. Mydria-
- Circulatory collapse sis, bradycardia, and hyperthermia are not associated with an
isocarboxazid overdose.
6. Which statement is true regard- Clozapine is more effective than other second-generation
ing antipsychotic medications? antipsychotics.
- All first- and second-genera-
tion antipsychotics are equally rationale: Clozapine is a second-generation antipsychotic
effective. medication that is more effective than other second-genera-
- Second-generation antipsy- tion antipsychotics. Most (but not all) first- and second-gen-
chotics pose a risk of extrapyra- eration antipsychotics are equally effective.
midal symptoms. Second-generation antipsychotics may cause metabolic side
- First-generation antipsy- effects such as diabetes and dyslipidemia. First-generation
chotics pose a significant risk of antipsychotics may cause extrapyramidal side effects.
metabolic side effects
- Clozapine is more effective
than other second-generation
antipsychotics.
7.
Page 2 of 19 2 of 19 Page 2
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Which medication may lead to Levomilnacipran
bruxism?
- Vilazodone rationale: Serotonin reuptake inhibitors and serotonin/nor-
- Isocarboxazid epinephrine reuptake inhibitors may lead to bruxism.
- Clomipramine Levomilnacipran is a serotonin/norepinephrine reuptake in-
- Levomilnacipran hibitor that may cause bruxism. Vilazodone is an atypical
antidepressant that does not cause bruxism. Isocarboxazid is
a monoamine oxidase inhibitor that does not cause bruxism.
Clomipramine is a tricyclic antidepressant that does not cause
bruxism.
8. Which action will the nurse take Assess the client's respiratory status.
after stopping the antibiotic in-
fusion of a client who becomes rationale: The client is experiencing an allergic reaction that
restless and flushed, and be- may progress to anaphylaxis. Anaphylactic shock can lead
gins to wheeze during the ad- to respiratory distress as a result of laryngeal edema or se-
ministration of an antibiotic? vere bronchospasm. Assessing and maintaining the client's
- Check the client's tempera- airway is the priority. Checking the client's temperature and
ture. taking the client's blood pressure are not the priority; vital
- Take the client's blood pres- signs should be obtained after airway patency is ensured and
sure. maintained. Pulse oximetry is only one portion of the needed
- Obtain the client's pulse respiratory status assessment.
oximetry.
- Assess the client's respiratory
status.
9. Which reply by the the nurse is "These medications affect the chemicals used in communica-
appropriate when a client asks tion between nerve cells."
how psychotropic medications
work? rationale: Most psychotropic medications affect neurotrans-
- 'These medications decrease mitters such as dopamine and norepinephrine, which enter
the metabolic needs of your the synapses between neurons, allowing them to signal each
Page 3 of 19 3 of 19 Page 3
NURS 1240 Clinical Judgement EAQ
Study online at https://quizlet.com/_d2ubxd
1. When evaluating fluid loss for Directly proportional
a client with burns, which re-
lationship between a client's rationale: There is greater extravasation of fluid into the tis-
burned body surface area and sues as the amount of tissue involved increases. Thus the
fluid loss would the nurse con- relationship of fluid loss to body surface area is directly
sider? proportional. Formulas (e.g., Parkland [Baxter) are used to
- Equal estimate fluid loss based on percentage of body surface area
- Unrelated burned. Equal, unrelated, and inversely related options are
- Inversely related incorrect; the relationship is proportional.
- Directly proportional
2. Which area of the client's body Sacrum
would the nurse consider a
high risk for developing a pres- rationale: The sacrum is the center of the greatest body mass;
sure injury when caring for an elevated torso exerts pressure toward this area.
an older adult with Alzheimer Although the scapulae are at risk, they do not bear the great-
type dementia who consistently est body weight as when the client is in the semi-Fowler
sleeps in a semi-Fowler position position. The ischial spine bears the greatest pressure when
in bed? the client is in an upright sitting position.
- Sacrum Greater trochanter is at risk when the client is in a side-lying
- Scapulae position.
- Ischial spine
- Greater trochanter
3. Which condition is contraindi- Dementia
cated for St. John's wort herbal
therapy? rationale: St. John's wort is contraindicated for dementia; this
- Anxiety herbal therapy is used to treat anxiety. Bupropion therapy is
- Seizures contraindicated for seizures. Valerian (Valeriana officinalis) is
- Dementia contraindicated for cardiac disease.
- Cardiac disease
Page 1 of 19 1 of 19 Page 1
, NURS 1240 Clinical Judgement EAQ 2 NURS 1240 Clinical Judgement EAQ.pdf
NURS 1240 Clinical Judgement EAQ
Study online at https://quizlet.com/_d2ubxd
4. Which condition contraindi- Pregnancy
cates the use of ginseng herbal
therapy? rationale: Pregnancy is contraindicated for ginseng herbal
- Pregnancy therapy. Schizophrenia, bipolar depression, and Alzheimer
- Schizophrenia disease are contraindicated for St. John's Wort herbal therapy.
- Bipolar depression
- Alzheimer disease
5. Which toxic effect would the Circulatory collapse
nurse find in a client who has
overdosed on isocarboxazid? rationale: The clinical symptoms of monoamine oxidase in-
- Mydriasis hibitors (MAOls) generally appear after 12 hours of inges-
- Bradycardia tion.
- Hypothermia Circulatory collapse is associated with MAOI toxicity. Mydria-
- Circulatory collapse sis, bradycardia, and hyperthermia are not associated with an
isocarboxazid overdose.
6. Which statement is true regard- Clozapine is more effective than other second-generation
ing antipsychotic medications? antipsychotics.
- All first- and second-genera-
tion antipsychotics are equally rationale: Clozapine is a second-generation antipsychotic
effective. medication that is more effective than other second-genera-
- Second-generation antipsy- tion antipsychotics. Most (but not all) first- and second-gen-
chotics pose a risk of extrapyra- eration antipsychotics are equally effective.
midal symptoms. Second-generation antipsychotics may cause metabolic side
- First-generation antipsy- effects such as diabetes and dyslipidemia. First-generation
chotics pose a significant risk of antipsychotics may cause extrapyramidal side effects.
metabolic side effects
- Clozapine is more effective
than other second-generation
antipsychotics.
7.
Page 2 of 19 2 of 19 Page 2
, NURS 1240 Clinical Judgement EAQ 3 NURS 1240 Clinical Judgement EAQ.pdf
NURS 1240 Clinical Judgement EAQ
Study online at https://quizlet.com/_d2ubxd
Which medication may lead to Levomilnacipran
bruxism?
- Vilazodone rationale: Serotonin reuptake inhibitors and serotonin/nor-
- Isocarboxazid epinephrine reuptake inhibitors may lead to bruxism.
- Clomipramine Levomilnacipran is a serotonin/norepinephrine reuptake in-
- Levomilnacipran hibitor that may cause bruxism. Vilazodone is an atypical
antidepressant that does not cause bruxism. Isocarboxazid is
a monoamine oxidase inhibitor that does not cause bruxism.
Clomipramine is a tricyclic antidepressant that does not cause
bruxism.
8. Which action will the nurse take Assess the client's respiratory status.
after stopping the antibiotic in-
fusion of a client who becomes rationale: The client is experiencing an allergic reaction that
restless and flushed, and be- may progress to anaphylaxis. Anaphylactic shock can lead
gins to wheeze during the ad- to respiratory distress as a result of laryngeal edema or se-
ministration of an antibiotic? vere bronchospasm. Assessing and maintaining the client's
- Check the client's tempera- airway is the priority. Checking the client's temperature and
ture. taking the client's blood pressure are not the priority; vital
- Take the client's blood pres- signs should be obtained after airway patency is ensured and
sure. maintained. Pulse oximetry is only one portion of the needed
- Obtain the client's pulse respiratory status assessment.
oximetry.
- Assess the client's respiratory
status.
9. Which reply by the the nurse is "These medications affect the chemicals used in communica-
appropriate when a client asks tion between nerve cells."
how psychotropic medications
work? rationale: Most psychotropic medications affect neurotrans-
- 'These medications decrease mitters such as dopamine and norepinephrine, which enter
the metabolic needs of your the synapses between neurons, allowing them to signal each
Page 3 of 19 3 of 19 Page 3
