NURS 1240 CLINICAL JUDGEMENT EAQ EXAM QUESTIONS AND
ANSWERS
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 ANSWER✅✅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 ANSWER✅✅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 ANSWER✅✅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 ANSWER✅✅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 ANSWER✅✅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
ANSWER✅✅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 ANSWER✅✅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.
- Take the client's blood pressure.
- Obtain the client's pulse oximetry.
- Assess the client's respiratory status. - CORRECT ANSWER✅✅Assess the client's respiratory status.
rationale: The client is experiencing an allergic reaction that may progress to anaphylaxis. Anaphylactic
shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing
ANSWERS
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 ANSWER✅✅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 ANSWER✅✅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 ANSWER✅✅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 ANSWER✅✅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 ANSWER✅✅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
ANSWER✅✅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 ANSWER✅✅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.
- Take the client's blood pressure.
- Obtain the client's pulse oximetry.
- Assess the client's respiratory status. - CORRECT ANSWER✅✅Assess the client's respiratory status.
rationale: The client is experiencing an allergic reaction that may progress to anaphylaxis. Anaphylactic
shock can lead to respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing
