Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse finds a client who has type 1 diabetes mellitus lying in bed, sweating, tachycardic, and reporting feeling lightheaded and shaky. Which of the following complications should the nurse suspect?
A. Ketoacidosis
Choice A: Ketoacidosis. This is incorrect because ketoacidosis is a complication of hyperglycemia, not hypoglycemia. Ketoacidosis occurs when the body breaks down fat for energy due to insufficient insulin, resulting in the accumulation of ketones and acids in the blood. Ketoacidosis can cause symptoms such as nausea, vomiting, abdominal pain, fruity breath odor, deep and rapid breathing, and altered mental status.
B. Hyperglycemia
Choice B: Hyperglycemia. This is incorrect because hyperglycemia is a condition of high blood glucose, not low blood glucose. Hyperglycemia can occur due to insufficient insulin, excessive carbohydrate intake, infection, stress, or illness. Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, blurred vision, fatigue, and headache.
C. Hypoglycemia
Choice C: Hypoglycemia. This is correct because hypoglycemia is a condition of low blood glucose, which can occur due to excessive insulin, inadequate carbohydrate intake, exercise, alcohol consumption, or medication interactions. Hypoglycemia can cause symptoms such as sweating, tachycardia, palpitations, tremors, hunger, anxiety, confusion, dizziness, weakness, and seizures.
D. Nephropathy
Choice D: Nephropathy. This is incorrect because nephropathy is a complication of chronic hyperglycemia, not acute hypoglycemia. Nephropathy is a kidney disease that results from damage to the small blood vessels and glomeruli in the kidneys due to high blood glucose levels. Nephropathy can cause symptoms such as proteinuria, edema, hypertension, and renal failure.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Monroe College NY PN 23NS SP 126 Proctored Exam 3. Take the full exam now
Full Explanation
Choice A: Ketoacidosis. This is incorrect because ketoacidosis is a complication of hyperglycemia, not hypoglycemia. Ketoacidosis occurs when the body breaks down fat for energy due to insufficient insulin, resulting in the accumulation of ketones and acids in the blood. Ketoacidosis can cause symptoms such as nausea, vomiting, abdominal pain, fruity breath odor, deep and rapid breathing, and altered mental status.
Choice B: Hyperglycemia. This is incorrect because hyperglycemia is a condition of high blood glucose, not low blood glucose. Hyperglycemia can occur due to insufficient insulin, excessive carbohydrate intake, infection, stress, or illness. Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, blurred vision, fatigue, and headache.
Choice C: Hypoglycemia. This is correct because hypoglycemia is a condition of low blood glucose, which can occur due to excessive insulin, inadequate carbohydrate intake, exercise, alcohol consumption, or medication interactions. Hypoglycemia can cause symptoms such as sweating, tachycardia, palpitations, tremors, hunger, anxiety, confusion, dizziness, weakness, and seizures.
Choice D: Nephropathy. This is incorrect because nephropathy is a complication of chronic hyperglycemia, not acute hypoglycemia. Nephropathy is a kidney disease that results from damage to the small blood vessels and glomeruli in the kidneys due to high blood glucose levels. Nephropathy can cause symptoms such as proteinuria, edema, hypertension, and renal failure.
Similar Questions
A nurse is assisting with teaching a newly licensed nurse about parenteral nutrition (PN). Which of the following information should the nurse include in the teaching?
A. Weigh the client weekly.
Choice A: Weigh the client weekly. This is incorrect because the client receiving PN should be weighed daily, not weekly, to monitor fluid balance and nutritional status. The nurse should also measure the client’s intake and output, blood glucose, electrolytes, and other laboratory values daily.
B. Reduce the rate of the solution gradually to discontinue.
Choice B: Reduce the rate of the solution gradually to discontinue. This is correct because the nurse should taper off the PN solution slowly to prevent rebound hypoglycemia, which can occur when the high concentration of glucose in the PN solution is abruptly stopped. The nurse should follow the provider’s orders or the facility’s protocol for reducing and discontinuing PN.
C. Remove solution from refrigerator 2 hr before infusion.
Choice C: Remove solution from refrigerator 2 hr before infusion. This is incorrect because the nurse should remove the PN solution from the refrigerator 30 to 60 minutes before infusion, not 2 hr, to allow it to reach room temperature. Infusing a cold solution can cause discomfort, vasoconstriction, and impaired absorption of nutrients.
D. Shake the solution before hanging if there is a layer of fat present on the top.
Choice D: Shake the solution before hanging if there is a layer of fat present on the top. This is incorrect because the nurse should not shake the PN solution at all, as this can cause fat emulsion droplets to coalesce and form large particles that can clog the filter or cause embolism. The nurse should gently invert or roll the PN solution container to mix it if there is any separation of components.
Full Explanation
Choice A: Weigh the client weekly. This is incorrect because the client receiving PN should be weighed daily, not weekly, to monitor fluid balance and nutritional status. The nurse should also measure the client’s intake and output, blood glucose, electrolytes, and other laboratory values daily.
Choice B: Reduce the rate of the solution gradually to discontinue. This is correct because the nurse should taper off the PN solution slowly to prevent rebound hypoglycemia, which can occur when the high concentration of glucose in the PN solution is abruptly stopped. The nurse should follow the provider’s orders or the facility’s protocol for reducing and discontinuing PN.
Choice C: Remove solution from refrigerator 2 hr before infusion. This is incorrect because the nurse should remove the PN solution from the refrigerator 30 to 60 minutes before infusion, not 2 hr, to allow it to reach room temperature. Infusing a cold solution can cause discomfort, vasoconstriction, and impaired absorption of nutrients.
Choice D: Shake the solution before hanging if there is a layer of fat present on the top. This is incorrect because the nurse should not shake the PN solution at all, as this can cause fat emulsion droplets to coalesce and form large particles that can clog the filter or cause embolism. The nurse should gently invert or roll the PN solution container to mix it if there is any separation of components.
A charge nurse is reinforcing teaching with a newly licensed nurse about the common link between ulcerative colitis and Crohn’s disease. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “Both illnesses result in malabsorption of nutrients.”
Choice A: Both illnesses result in malabsorption of nutrients. This is incorrect because malabsorption of nutrients is more common in Crohn’s disease than in ulcerative colitis. Crohn’s disease can affect any part of the gastrointestinal tract, including the small intestine, where most of the nutrient absorption occurs. Ulcerative colitis mainly affects the colon and rectum, which are responsible for water and electrolyte absorption.
B. “Both illnesses begin in the rectum.”
Choice B: Both illnesses begin in the rectum. This is incorrect because ulcerative colitis usually begins in the rectum and spreads proximally to the colon, while Crohn’s disease can begin anywhere in the gastrointestinal tract, from the mouth to the anus.
C. “Both illnesses manifest fistula formation.”
Choice C: Both illnesses manifest fistula formation. This is incorrect because fistula formation is more common in Crohn’s disease than in ulcerative colitis. Fistulas are abnormal connections between different parts of the gastrointestinal tract or other organs, such as the bladder, vagina, or skin. They are caused by inflammation, ulceration, and infection that penetrate through the bowel wall.
D. “Both illnesses are inflammatory in nature.”
Choice D: Both illnesses are inflammatory in nature. This is correct because both ulcerative colitis and Crohn’s disease are types of inflammatory bowel disease (IBD), which are chronic conditions that cause inflammation and damage to the gastrointestinal tract. The exact cause of IBD is unknown, but it may involve genetic, immune, environmental, and microbial factors.
Full Explanation
Choice A: Both illnesses result in malabsorption of nutrients. This is incorrect because malabsorption of nutrients is more common in Crohn’s disease than in ulcerative colitis. Crohn’s disease can affect any part of the gastrointestinal tract, including the small intestine, where most of the nutrient absorption occurs. Ulcerative colitis mainly affects the colon and rectum, which are responsible for water and electrolyte absorption.
Choice B: Both illnesses begin in the rectum. This is incorrect because ulcerative colitis usually begins in the rectum and spreads proximally to the colon, while Crohn’s disease can begin anywhere in the gastrointestinal tract, from the mouth to the anus.
Choice C: Both illnesses manifest fistula formation. This is incorrect because fistula formation is more common in Crohn’s disease than in ulcerative colitis. Fistulas are abnormal connections between different parts of the gastrointestinal tract or other organs, such as the bladder, vagina, or skin. They are caused by inflammation, ulceration, and infection that penetrate through the bowel wall.
Choice D: Both illnesses are inflammatory in nature. This is correct because both ulcerative colitis and Crohn’s disease are types of inflammatory bowel disease (IBD), which are chronic conditions that cause inflammation and damage to the gastrointestinal tract. The exact cause of IBD is unknown, but it may involve genetic, immune, environmental, and microbial factors.
A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report?
A. Sensitivity to cold
Choice A: Sensitivity to cold. This is incorrect because sensitivity to cold is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased metabolism and heat production, which makes them more sensitive to heat.
B. Frequent mood changes
Choice B: Frequent mood changes. This is correct because frequent mood changes are a manifestation of hyperthyroidism. Clients with hyperthyroidism have increased levels of thyroid hormones, which can affect their nervous system and cause irritability, anxiety, nervousness, or emotional instability.
C. Weight gain
Choice C: Weight gain. This is incorrect because weight gain is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased metabolism and appetite, which makes them lose weight or have difficulty gaining weight.
D. Constipation
Choice D: Constipation. This is incorrect because constipation is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased bowel motility and peristalsis, which makes them more prone to diarrhea or frequent stools.
Full Explanation
Choice A: Sensitivity to cold. This is incorrect because sensitivity to cold is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased metabolism and heat production, which makes them more sensitive to heat.
Choice B: Frequent mood changes. This is correct because frequent mood changes are a manifestation of hyperthyroidism. Clients with hyperthyroidism have increased levels of thyroid hormones, which can affect their nervous system and cause irritability, anxiety, nervousness, or emotional instability.
Choice C: Weight gain. This is incorrect because weight gain is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased metabolism and appetite, which makes them lose weight or have difficulty gaining weight.
Choice D: Constipation. This is incorrect because constipation is a manifestation of hypothyroidism, not hyperthyroidism. Clients with hyperthyroidism have increased bowel motility and peristalsis, which makes them more prone to diarrhea or frequent stools.