NURS 1240 Clinical Judgement EAQ

NURS 1240 Clinical Judgement EAQ
2026-2027
Question 1
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.


Question 2
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.


Question 3
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.


Question 4
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.


Question 5
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.


Question 6
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.


Question 7

,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.


Question 8
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 and maintaining the client's airway is the priority. Checking the
client's temperature and taking the client's blood pressure are not the priority; vital signs
should be obtained after airway patency is ensured and maintained. Pulse oximetry is only
one portion of the needed respiratory status assessment.


Question 9
Which reply by the the nurse is appropriate when a client asks how psychotropic medications
work?
- 'These medications decrease the metabolic needs of your brain."
- "These medications increase the production of healthy nervous tissue."
- "These medications affect the chemicals used in communication between nerve cells."
- "These medications regulate sensory input received from the external environment!"
Correct Answer
"These medications affect the chemicals used in communication between nerve cells."

rationale: Most psychotropic medications affect neurotransmitters such as dopamine and
norepinephrine, which enter the synapses between neurons, allowing them to signal each
other. Psychotropic medications do not work by changing the metabolic needs of the brain.

, They do not increase the production of nervous tissue. Although there may be some effect
on sensory input, this is because of the change in neurotransmitters


Question 10
Which mechanism of action would the nurse identify for levodopa therapy prescribed to a
client diagnosed with Parkinson disease?
- Blocks the effects of acetylcholine
- Increases the production of dopamine
- Restores the dopamine levels in the brain
- Promotes the production of acetylcholine
Correct Answer
Restores the dopamine levels in the brain

rationale: Levodopa is a precursor of dopamine, a catecholamine neurotransmitter; it
increases dopamine levels in the brain that are depleted in Parkinson disease. Blocking the
effects of acetylcholine is accomplished by anticholinergic medications. Increasing the
production of dopamine is ineffective because it is believed that the cells that produce
dopamine have degenerated in Parkinson disease. Levodopa does not affect acetylcholine
production.


Question 11
Which medication is the most common cause of extrapyramidal side effects (EPSs)?
- Clozapine
- Haloperidol
- Risperidone
- Aripiprazole
Correct Answer
Haloperidol

rationale: Haloperidol is a typical antipsychotic that commonly causes extrapyramidal side
effects. Clozapine is an atvpical antipsychotic that has a low risk of causing extrapyramidal
side effects. Risperidone and aripiprazole have a low risk of causing extrapyramidal side
effects.


Question 12
Place the following nursing actions in the correct order for a client with esophageal varices
prescribed a blood transfusion.
- Check the client's vital signs.
- Establish intravenous (IV) access with IV normal saline.
- Verify the blood product with another nurse against the client's identification (ID) bracelet.
- Monitor the client's vital signs and status according to agency policy
Correct Answer
- Check the client's vital signs.
- Establish intravenous (IV) access with IV normal saline.
- Verify the blood product with another nurse against the client's identification (ID) bracelet.
- Monitor the client's vital signs and status according to agency policy