Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress.
Which of the following manifestations should the nurse include?
A. Decreased blood pressure.
Choice A is wrong because the fight-or-flight response increases blood pressure by constricting blood vessels and increasing heart rate.
B. Bronchial airway constriction.
Choice B is wrong because the fight-or-flight response causes bronchial airway dilation to allow more oxygen intake and facilitate breathing.
C. Hypoglycemia.
Choice C is wrong because the fight-or-flight response causes hyperglycemia by stimulating the release of glucose from the liver and muscles to provide energy. Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for blood glucose are 70 mg/dL to 100 mg/dL, and for pupil size are 2 mm to 6 mm.
D. Dilated pupils.
This is because the fight-or-flight response activates the sympathetic nervous system, which causes the pupils to dilate to allow more light and improve vision.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Sp23 N144 FINAL Proctored Exam. Take the full exam now
Full Explanation
This is because the fight-or-flight response activates the sympathetic nervous system, which causes the pupils to dilate to allow more light and improve vision.
Choice A is wrong because the fight-or-flight response increases blood pressure by constricting blood vessels and increasing heart rate.
Choice B is wrong because the fight-or-flight response causes bronchial airway dilation to allow more oxygen intake and facilitate breathing.
Choice C is wrong because the fight-or-flight response causes hyperglycemia by stimulating the release of glucose from the liver and muscles to provide energy.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg, for blood glucose are 70 mg/dL to 100 mg/dL, and for pupil size are 2 mm to 6 mm.
Similar Questions
Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?
A. Fluid volume excess.
Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be risk for deficient fluid volume.
B. Risk for infection.
nfection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.
C. Ineffective thermoregulation.
Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.
D. Pain.
Appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.
Full Explanation
Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be the risk for deficient fluid volume.
Choice B. Risk for infection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.
Choice C. Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.
Choice D. Pain is correct because appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.
The nurse knows that infants have a high risk of hypothermia due to decreased brown fat, immature skin, and poorly developed thermoregulatory mechanism.
Which nursing intervention is done to prevent heat loss by conduction?
A. Closing doors and windows to prevent draft (current of air with motion).
Choice A is wrong because closing doors and windows to prevent draft (current of air with motion) would prevent heat loss by convection, not conduction. Convection is the transfer of heat from a body to moving molecules such as air or liquid.
B. Keeping a hat on the baby’s head.
Choice B is wrong because keeping a hat on the baby’s head would prevent heat loss by radiation, not conduction. Radiation is the transfer of heat from a body to the surroundings by electromagnetic waves.
C. Thoroughly drying infant after a bath.
Choice C is wrong because thoroughly drying infant after a bath would prevent heat loss by evaporation, not conduction. Evaporation is the process of liquid changing into gas and carrying away heat from the body surface.
D. Placing a warm blanket on the scale prior to obtaining baby’s weight.
This is because heat loss by conduction occurs when two objects with different temperatures come into direct contact with each other. The baby’s skin would lose heat to the cold scale by conduction if there was no warm blanket between them.
Full Explanation
This is because heat loss by conduction occurs when two objects with different temperatures come into direct contact with each other. The baby’s skin would lose heat to the cold scale by conduction if there was no warm blanket between them.
Choice A is wrong because closing doors and windows to prevent draft (current of air with motion) would prevent heat loss by convection, not conduction. Convection is the transfer of heat from a body to moving molecules such as air or liquid.
Choice B is wrong because keeping a hat on the baby’s head would prevent heat loss by radiation, not conduction. Radiation is the transfer of heat from a body to the surroundings by electromagnetic waves.
Choice C is wrong because thoroughly drying infant after a bath would prevent heat loss by evaporation, not conduction. Evaporation is the process of liquid changing into gas and carrying away heat from the body surface.
A client is admitted with an exacerbation of COPD. He has a long history of chronic bronchitis.
What physical finding does the nurse expect in a client with chronic bronchitis?
A. SpO2 >92%.
Choice A is wrong because SpO2 >92% is not a specific finding for chronic bronchitis. SpO2 is a measure of oxygen saturation in the blood and can vary depending on many factors, such as altitude, smoking, and lung diseases. SpO2 may be lower than normal in COPD patients due to airflow obstruction and impaired gas exchange.
B. Underweight.
Choice B is wrong because underweight is not a typical finding for chronic bronchitis. Underweight may be more associated with emphysema, which is another component of COPD that involves the destruction of alveolar walls and enlargement of air spaces. Emphysema can cause weight loss due to increased work of breathing and decreased appetite.
C. Bradypnea.
Choice C is wrong because bradypnea is not a common finding for chronic bronchitis. Bradypnea is abnormally slow breathing rate and can be caused by various conditions, such as brain injury, drug overdose, or sleep apnea. Chronic bronchitis usually causes tachypnea, which is abnormally fast breathing rate, due to hypoxia and hypercapnia.
D. Productive cough.
A client with chronic bronchitis is expected to have a cough that produces sputum for at least 3 months during two successive years. This is due to the hyperplasia of mucous glands and bronchial wall inflammation that occur in chronic bronchitis.
Full Explanation
A client with chronic bronchitis is expected to have a cough that produces sputum for at least 3 months during two successive years. This is due to the hyperplasia of mucous glands and bronchial wall inflammation that occur in chronic bronchitis.
Choice A is wrong because SpO2 >92% is not a specific finding for chronic bronchitis.
SpO2 is a measure of oxygen saturation in the blood and can vary depending on many factors, such as altitude, smoking, and lung diseases. SpO2 may be lower than normal in COPD patients due to airflow obstruction and impaired gas exchange.
Choice B is wrong because underweight is not a typical finding for chronic bronchitis.
Underweight may be more associated with emphysema, which is another component of COPD that involves the destruction of alveolar walls and enlargement of air spaces. Emphysema can cause weight loss due to increased work of breathing and decreased appetite.
Choice C is wrong because bradypnea is not a common finding for chronic bronchitis.
Bradypnea is abnormally slow breathing rate and can be caused by various conditions, such as brain injury, drug overdose, or sleep apnea. Chronic bronchitis usually causes tachypnea, which is abnormally fast breathing rate, due to hypoxia and hypercapnia.