NURS 1240 Clinical Judgement EAQ || Already Graded A+.
When evaluating fluid loss for a client with burns, which relationship between a client's burned
body surface area and fluid loss would the nurse consider?
- Equal
- Unrelated
- Inversely related
- Directly proportional correct answers Directly proportional
rationale: There is greater extravasation of fluid into the tissues as the amount of tissue involved
increases. Thus the relationship of fluid loss to body surface area is directly proportional.
Formulas (e.g., Parkland [Baxter) are used to estimate fluid loss based on percentage of body
surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship
is proportional.
Which area of the client's body would the nurse consider a high risk for developing a pressure
injury when caring for an older adult with Alzheimer type dementia who consistently sleeps in a
semi-Fowler position in bed?
- Sacrum
- Scapulae
- Ischial spine
- Greater trochanter correct answers Sacrum
rationale: The sacrum is the center of the greatest body mass; an elevated torso exerts pressure
toward this area.
Although the scapulae are at risk, they do not bear the greatest body weight as when the client is
in the semi-Fowler position. The ischial spine bears the greatest pressure when the client is in an
upright sitting position.
Greater trochanter is at risk when the client is in a side-lying position.
,Which condition is contraindicated for St. John's wort herbal therapy?
- Anxiety
- Seizures
- Dementia
- Cardiac disease correct answers Dementia
rationale: St. John's wort is contraindicated for dementia; this herbal therapy is used to treat
anxiety. Bupropion therapy is contraindicated for seizures. Valerian (Valeriana officinalis) is
contraindicated for cardiac disease.
Which condition contraindicates the use of ginseng herbal therapy?
- Pregnancy
- Schizophrenia
- Bipolar depression
- Alzheimer disease correct answers Pregnancy
rationale: Pregnancy is contraindicated for ginseng herbal therapy. Schizophrenia, bipolar
depression, and Alzheimer disease are contraindicated for St. John's Wort herbal therapy.
Which toxic effect would the nurse find in a client who has overdosed on isocarboxazid?
- Mydriasis
- Bradycardia
- Hypothermia
- Circulatory collapse correct answers Circulatory collapse
rationale: The clinical symptoms of monoamine oxidase inhibitors (MAOls) generally appear
after 12 hours of ingestion.
Circulatory collapse is associated with MAOI toxicity. Mydriasis, bradycardia, and hyperthermia
are not associated with an isocarboxazid overdose.
, Which statement is true regarding antipsychotic medications?
- All first- and second-generation antipsychotics are equally effective.
- Second-generation antipsychotics pose a risk of extrapyramidal symptoms.
- First-generation antipsychotics pose a significant risk of metabolic side effects
- Clozapine is more effective than other second-generation antipsychotics. correct answers
Clozapine is more effective than other second-generation antipsychotics.
rationale: Clozapine is a second-generation antipsychotic medication that is more effective than
other second-generation antipsychotics. Most (but not all) first- and second-generation
antipsychotics are equally effective.
Second-generation antipsychotics may cause metabolic side effects such as diabetes and
dyslipidemia. First-generation antipsychotics may cause extrapyramidal side effects.
Which medication may lead to bruxism?
- Vilazodone
- Isocarboxazid
- Clomipramine
- Levomilnacipran correct answers Levomilnacipran
rationale: Serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors may
lead to bruxism.
Levomilnacipran is a serotonin/norepinephrine reuptake inhibitor 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.
Which action will the nurse take after stopping the antibiotic infusion of a client who becomes
restless and flushed, and begins to wheeze during the administration of an antibiotic?
- Check the client's temperature.
When evaluating fluid loss for a client with burns, which relationship between a client's burned
body surface area and fluid loss would the nurse consider?
- Equal
- Unrelated
- Inversely related
- Directly proportional correct answers Directly proportional
rationale: There is greater extravasation of fluid into the tissues as the amount of tissue involved
increases. Thus the relationship of fluid loss to body surface area is directly proportional.
Formulas (e.g., Parkland [Baxter) are used to estimate fluid loss based on percentage of body
surface area burned. Equal, unrelated, and inversely related options are incorrect; the relationship
is proportional.
Which area of the client's body would the nurse consider a high risk for developing a pressure
injury when caring for an older adult with Alzheimer type dementia who consistently sleeps in a
semi-Fowler position in bed?
- Sacrum
- Scapulae
- Ischial spine
- Greater trochanter correct answers Sacrum
rationale: The sacrum is the center of the greatest body mass; an elevated torso exerts pressure
toward this area.
Although the scapulae are at risk, they do not bear the greatest body weight as when the client is
in the semi-Fowler position. The ischial spine bears the greatest pressure when the client is in an
upright sitting position.
Greater trochanter is at risk when the client is in a side-lying position.
,Which condition is contraindicated for St. John's wort herbal therapy?
- Anxiety
- Seizures
- Dementia
- Cardiac disease correct answers Dementia
rationale: St. John's wort is contraindicated for dementia; this herbal therapy is used to treat
anxiety. Bupropion therapy is contraindicated for seizures. Valerian (Valeriana officinalis) is
contraindicated for cardiac disease.
Which condition contraindicates the use of ginseng herbal therapy?
- Pregnancy
- Schizophrenia
- Bipolar depression
- Alzheimer disease correct answers Pregnancy
rationale: Pregnancy is contraindicated for ginseng herbal therapy. Schizophrenia, bipolar
depression, and Alzheimer disease are contraindicated for St. John's Wort herbal therapy.
Which toxic effect would the nurse find in a client who has overdosed on isocarboxazid?
- Mydriasis
- Bradycardia
- Hypothermia
- Circulatory collapse correct answers Circulatory collapse
rationale: The clinical symptoms of monoamine oxidase inhibitors (MAOls) generally appear
after 12 hours of ingestion.
Circulatory collapse is associated with MAOI toxicity. Mydriasis, bradycardia, and hyperthermia
are not associated with an isocarboxazid overdose.
, Which statement is true regarding antipsychotic medications?
- All first- and second-generation antipsychotics are equally effective.
- Second-generation antipsychotics pose a risk of extrapyramidal symptoms.
- First-generation antipsychotics pose a significant risk of metabolic side effects
- Clozapine is more effective than other second-generation antipsychotics. correct answers
Clozapine is more effective than other second-generation antipsychotics.
rationale: Clozapine is a second-generation antipsychotic medication that is more effective than
other second-generation antipsychotics. Most (but not all) first- and second-generation
antipsychotics are equally effective.
Second-generation antipsychotics may cause metabolic side effects such as diabetes and
dyslipidemia. First-generation antipsychotics may cause extrapyramidal side effects.
Which medication may lead to bruxism?
- Vilazodone
- Isocarboxazid
- Clomipramine
- Levomilnacipran correct answers Levomilnacipran
rationale: Serotonin reuptake inhibitors and serotonin/norepinephrine reuptake inhibitors may
lead to bruxism.
Levomilnacipran is a serotonin/norepinephrine reuptake inhibitor 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.
Which action will the nurse take after stopping the antibiotic infusion of a client who becomes
restless and flushed, and begins to wheeze during the administration of an antibiotic?
- Check the client's temperature.
