Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 22-year-old pregnant woman reports craving and eating non-food items such as ice, clay, and dirt. Which of the following statements by the nurse is correct?
A. "You should be encouraged to eat more of these items to satisfy cravings.
"You should be encouraged to eat more of these items to satisfy cravings." is incorrect because consuming non-food items like ice, clay, or dirt can be harmful. These substances may contain toxins or pathogens and can interfere with nutrient absorption. Encouraging this behavior would be unsafe.
B. "This is a normal behavior during pregnancy and does not require intervention."
"This is a normal behavior during pregnancy and does not require intervention." is incorrect because while cravings are common in pregnancy, PICA is an abnormal eating behavior involving non-food items and requires assessment and intervention due to potential health risks.
C. This behavior, called PICA, may lead to nutritional deficiencies and should be assessed."
"This behavior, called PICA, may lead to nutritional deficiencies and should be assessed." is correct. PICA is the recurrent consumption of non-nutritive substances and is often associated with iron deficiency anemia and other nutritional deficiencies. The nurse should assess for nutritional status, laboratory abnormalities, and educate the client on potential risks to both mother and fetus.
D. "PICA only occurs in the first trimester and will resolve on its own."
"PICA only occurs in the first trimester and will resolve on its own." is incorrect because PICA can occur at any time during pregnancy and may persist throughout gestation if untreated. It does not resolve spontaneously in all cases.
This question is an excerpt from Nurse Dive's nursing test bank - Ati dmmsn 650 OB/Pediatrics Proctored Exams. Take the full exam now
Full Explanation
A. "You should be encouraged to eat more of these items to satisfy cravings." is incorrect because consuming non-food items like ice, clay, or dirt can be harmful. These substances may contain toxins or pathogens and can interfere with nutrient absorption. Encouraging this behavior would be unsafe.
B. "This is a normal behavior during pregnancy and does not require intervention." is incorrect because while cravings are common in pregnancy, PICA is an abnormal eating behavior involving non-food items and requires assessment and intervention due to potential health risks.
C. "This behavior, called PICA, may lead to nutritional deficiencies and should be assessed." is correct. PICA is the recurrent consumption of non-nutritive substances and is often associated with iron deficiency anemia and other nutritional deficiencies. The nurse should assess for nutritional status, laboratory abnormalities, and educate the client on potential risks to both mother and fetus.
D. "PICA only occurs in the first trimester and will resolve on its own." is incorrect because PICA can occur at any time during pregnancy and may persist throughout gestation if untreated. It does not resolve spontaneously in all cases.
Similar Questions
The nurse is assessing a newborn who is 12 hours old. Which symptoms would indicate the newborn is experiencing respiratory distress? (Select all that apply)
A. inspiratory stridor
Inspiratory stridor is correct. Stridor is a high-pitched, noisy sound during inspiration caused by partial obstruction of the upper airway, such as laryngeal edema or congenital anomalies. In a newborn, stridor indicates that the infant is struggling to get enough air into the lungs, and immediate assessment is needed to prevent hypoxia.
B. increased appetite
Increased appetite is incorrect. Feeding difficulties, not increased appetite, are more likely in a newborn experiencing respiratory distress. Labored breathing can make sucking and swallowing difficult, which may lead to poor intake or fatigue during feeding.
C. retractions
Retractions are correct. Retractions occur when the intercostal muscles, subcostal areas, or suprasternal notch pull inward with inspiration. This reflects increased respiratory effort because the newborn is working harder to expand the lungs against resistance. Retractions are a classic and easily observable sign of respiratory distress.
D. nasal flaring
Nasal flaring is correct. Flaring of the nostrils occurs as the infant attempts to increase airflow into the lungs. This is a compensatory mechanism to reduce airway resistance and improve oxygen intake. Nasal flaring is particularly noticeable in newborns because their nasal passages are narrow and easily obstructed.
E. grunting
Grunting is correct. Grunting is an expiratory sound made when the newborn partially closes the glottis while exhaling. This helps maintain alveolar pressure and improve gas exchange, which is a compensatory response to lung immaturity or alveolar collapse. Persistent grunting is a red flag for significant respiratory compromise.
Full Explanation
A. Inspiratory stridor is correct. Stridor is a high-pitched, noisy sound during inspiration caused by partial obstruction of the upper airway, such as laryngeal edema or congenital anomalies. In a newborn, stridor indicates that the infant is struggling to get enough air into the lungs, and immediate assessment is needed to prevent hypoxia.
B. Increased appetite is incorrect. Feeding difficulties, not increased appetite, are more likely in a newborn experiencing respiratory distress. Labored breathing can make sucking and swallowing difficult, which may lead to poor intake or fatigue during feeding.
C. Retractions are correct. Retractions occur when the intercostal muscles, subcostal areas, or suprasternal notch pull inward with inspiration. This reflects increased respiratory effort because the newborn is working harder to expand the lungs against resistance. Retractions are a classic and easily observable sign of respiratory distress.
D. Nasal flaring is correct. Flaring of the nostrils occurs as the infant attempts to increase airflow into the lungs. This is a compensatory mechanism to reduce airway resistance and improve oxygen intake. Nasal flaring is particularly noticeable in newborns because their nasal passages are narrow and easily obstructed.
E. Grunting is correct. Grunting is an expiratory sound made when the newborn partially closes the glottis while exhaling. This helps maintain alveolar pressure and improve gas exchange, which is a compensatory response to lung immaturity or alveolar collapse. Persistent grunting is a red flag for significant respiratory compromise.
A 7-year-old child is brought to the clinic due to fatigue, slowed growth, and constipation. On examination, the child has dry skin, a puffy face, and a hoarse voice. Which of the following conditions should the nurse suspect?
A. Hypothyroidism
Hypothyroidism is correct. The child’s fatigue, slowed growth, and constipation, along with physical findings such as dry skin, puffy face, and hoarse voice, are classic signs of hypothyroidism, a condition caused by insufficient thyroid hormone production. In children, untreated hypothyroidism can lead to growth retardation, developmental delays, and delayed puberty.
B. Cushing's Syndrome
Cushing's Syndrome is incorrect because it is characterized by weight gain, truncal obesity, moon face, buffalo hump, and skin changes like striae, often with hypertension and hyperglycemia. Fatigue and constipation are less prominent, and slowed growth is not typically associated with early Cushing's.
C. Hyperthyroidism
Hyperthyroidism is incorrect because it usually presents with weight loss, increased appetite, tachycardia, heat intolerance, hyperactivity, and rapid growth, which are opposite to the findings in this child.
D. Type 1 Diabetes Mellitus
Type 1 Diabetes Mellitus is incorrect because it is usually presents with polyuria, polydipsia, polyphagia, and weight loss. Constipation, hoarse voice, and dry skin are not characteristic of diabetes.
Full Explanation
A. Hypothyroidism is correct. The child’s fatigue, slowed growth, and constipation, along with physical findings such as dry skin, puffy face, and hoarse voice, are classic signs of hypothyroidism, a condition caused by insufficient thyroid hormone production. In children, untreated hypothyroidism can lead to growth retardation, developmental delays, and delayed puberty.
B. Cushing's Syndrome is incorrect because it is characterized by weight gain, truncal obesity, moon face, buffalo hump, and skin changes like striae, often with hypertension and hyperglycemia. Fatigue and constipation are less prominent, and slowed growth is not typically associated with early Cushing's.
C. Hyperthyroidism is incorrect because it usually presents with weight loss, increased appetite, tachycardia, heat intolerance, hyperactivity, and rapid growth, which are opposite to the findings in this child.
D. Type 1 Diabetes Mellitus is incorrect because it is usually presents with polyuria, polydipsia, polyphagia, and weight loss. Constipation, hoarse voice, and dry skin are not characteristic of diabetes.
A 6-year-old child with asthma is prescribed albuterol as a rescue inhaler for acute exacerbations. The nurse is educating the parents about the proper use of the inhaler. Which of the following instructions is most important for the nurse to provide?
A. Use the inhaler as needed during an asthma attack, but avoid overuse
Use the inhaler as needed during an asthma attack, but avoid overuse is correct. Albuterol is a short-acting beta-agonist (SABA) used as a rescue inhaler to relieve acute bronchospasm. It should be used during episodes of wheezing, coughing, or shortness of breath, but parents should be instructed not to overuse it, as excessive use can cause tachycardia, tremors, and decreased effectiveness. Monitoring frequency helps identify poorly controlled asthma that may require a review of the maintenance regimen.
B. Use the inhaler only when the child has difficulty breathing during physical activity
Use the inhaler only when the child has difficulty breathing during physical activity is partially correct, but limiting it to activity-induced symptoms alone ignores other potential triggers, such as allergens or infections, which can also precipitate asthma attacks. Rescue inhalers are intended for all acute exacerbations, not just activity-induced ones.
C. Use the inhaler every 4 hours as a preventative measure
Use the inhaler every 4 hours as a preventative measure is incorrect. Albuterol is not a maintenance or preventive medication; daily scheduled use is not recommended unless prescribed for specific short-term prophylaxis (e.g., before exercise). Long-term control requires inhaled corticosteroids or other controller medications, not a SABA.
D. Limit the use of the inhaler to prevent dependency on the medication
Limit the use of the inhaler to prevent dependency on the medication is incorrect. Albuterol does not cause drug dependency, but overuse can indicate poor asthma control. The focus should be on appropriate use for symptom relief rather than fear of dependency.
Full Explanation
A. Use the inhaler as needed during an asthma attack, but avoid overuse is correct. Albuterol is a short-acting beta-agonist (SABA) used as a rescue inhaler to relieve acute bronchospasm. It should be used during episodes of wheezing, coughing, or shortness of breath, but parents should be instructed not to overuse it, as excessive use can cause tachycardia, tremors, and decreased effectiveness. Monitoring frequency helps identify poorly controlled asthma that may require a review of the maintenance regimen.
B. Use the inhaler only when the child has difficulty breathing during physical activity is partially correct, but limiting it to activity-induced symptoms alone ignores other potential triggers, such as allergens or infections, which can also precipitate asthma attacks. Rescue inhalers are intended for all acute exacerbations, not just activity-induced ones.
C. Use the inhaler every 4 hours as a preventative measure is incorrect. Albuterol is not a maintenance or preventive medication; daily scheduled use is not recommended unless prescribed for specific short-term prophylaxis (e.g., before exercise). Long-term control requires inhaled corticosteroids or other controller medications, not a SABA.
D. Limit the use of the inhaler to prevent dependency on the medication is incorrect. Albuterol does not cause drug dependency, but overuse can indicate poor asthma control. The focus should be on appropriate use for symptom relief rather than fear of dependency.