Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching of a female client who has a family history of type 2 diabetes mellitus. The nurse should include which of the following risk factors for developing type 2 diabetes mellitus in the teaching?
A. Sedentary lifestyle
Choice A: Sedentary lifestyle. This is a risk factor for developing type 2 diabetes mellitus, which is a condition that occurs when the body becomes resistant to the action of insulin or does not produce enough insulin to maintain normal blood glucose levels. Insulin is a hormone that helps glucose enter the cells and be used for energy. A sedentary lifestyle can increase the risk of type 2 diabetes mellitus by reducing physical activity, which can improve insulin sensitivity and lower blood glucose levels.
B. Triglyceride level of 100 mg/dL
Choice B: Triglyceride level of 100 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Triglycerides are a type of fat that circulates in the blood and can be used for energy or stored in adipose tissue. A high triglyceride level can indicate an increased risk of cardiovascular disease, but it is not directly related to type 2 diabetes mellitus.
C. Blood glucose of 98 mg/dL
Choice C: Blood glucose of 98 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Blood glucose is the amount of glucose in the blood, which can vary depending on food intake, physical activity, and hormonal regulation. A high blood glucose level can indicate type 2 diabetes mellitus, but it is not a cause of it.
D. Recent viral infection
Choice D: Recent viral infection. This is not a risk factor for developing type 2 diabetes mellitus, but rather a possible trigger for type 1 diabetes mellitus, which is a condition that occurs when the immune system destroys the beta cells of the pancreas that produce insulin. A viral infection can trigger an autoimmune response that atacks the beta cells and causes type 1 diabetes mellitus.
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Full Explanation
Choice A: Sedentary lifestyle. This is a risk factor for developing type 2 diabetes mellitus, which is a condition that occurs when the body becomes resistant to the action of insulin or does not produce enough insulin to maintain normal blood glucose levels. Insulin is a hormone that helps glucose enter the cells and be used for energy. A sedentary lifestyle can increase the risk of type 2 diabetes mellitus by reducing physical activity, which can improve insulin sensitivity and lower blood glucose levels.
Choice B: Triglyceride level of 100 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Triglycerides are a type of fat that circulates in the blood and can be used for energy or stored in adipose tissue. A high triglyceride level can indicate an increased risk of cardiovascular disease, but it is not directly related to type 2 diabetes mellitus.
Choice C: Blood glucose of 98 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Blood glucose is the amount of glucose in the blood, which can vary depending on food intake, physical activity, and hormonal regulation. A high blood glucose level can indicate type 2 diabetes mellitus, but it is not a cause of it.
Choice D: Recent viral infection. This is not a risk factor for developing type 2 diabetes mellitus, but rather a possible trigger for type 1 diabetes mellitus, which is a condition that occurs when the immune system destroys the beta cells of the pancreas that produce insulin. A viral infection can trigger an autoimmune response that attacks the beta cells and causes type 1 diabetes mellitus.
Similar Questions
A nurse is collecting data from a client who has acute gastroenteritis. Which of the following data collection findings should the nurse identify as the priority?
A. Potassium 2.5 mEq/L
Choice A: Potassium 2.5 mEq/L. This is the priority data collection finding that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should identify potassium 2.5 mEq/L as the priority because it indicates hypokalemia, which is a low level of potassium in the blood. Potassium is an electrolyte that regulates the electrical activity of the heart and muscles. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis, which can be life-threatening.
B. Blood glucose 150 mg/dL
Choice B: Blood glucose 150 mg/dL. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Blood glucose 150 mg/dL indicates hyperglycemia, which is a high level of glucose in the blood. Hyperglycemia can be caused by dehydration, stress, infection, or medication side effects. Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, and fatigue. It can also lead to complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which are serious but not as urgent as hypokalemia.
C. Urine specific gravity 1.035
Choice C: Urine specific gravity 1.035. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Urine specific gravity 1.035 indicates concentrated urine, which can be caused by dehydration or fluid loss. Dehydration can result from vomiting and diarrhea, which are common symptoms of acute gastroenteritis. Dehydration can cause symptoms such as dry mucous membranes, tachycardia, hypotension, and oliguria. It can also lead to complications such as shock or kidney failure, which are serious but not as urgent as hypokalemia.
D. Weight loss of 3% of total body weight.
Choice D: Weight loss of 3% of total body weight. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Weight loss of 3% of total body weight indicates mild to moderate dehydration, which can be caused by fluid loss from vomiting and diarrhea. Weight loss can also reflect loss of muscle mass or fat tissue due to malnutrition or inflammation. Weight loss can affect the client’s nutritional status and immune function, but it is not as urgent as hypokalemia.
Full Explanation
Choice A: Potassium 2.5 mEq/L. This is the priority data collection finding that the nurse should identify according to the ABCDE principle, which prioritizes interventions based on airway, breathing, circulation, disability, and exposure. The nurse should identify potassium 2.5 mEq/L as the priority because it indicates hypokalemia, which is a low level of potassium in the blood. Potassium is an electrolyte that regulates the electrical activity of the heart and muscles. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis, which can be life-threatening.
Choice B: Blood glucose 150 mg/dL. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Blood glucose 150 mg/dL indicates hyperglycemia, which is a high level of glucose in the blood. Hyperglycemia can be caused by dehydration, stress, infection, or medication side effects.
Hyperglycemia can cause symptoms such as polyuria, polydipsia, polyphagia, and fatigue. It can also lead to complications such as diabetic ketoacidosis or hyperosmolar hyperglycemic state, which are serious but not as urgent as hypokalemia.
Choice C: Urine specific gravity 1.035. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Urine specific gravity 1.035 indicates concentrated urine, which can be caused by dehydration or fluid loss. Dehydration can result from vomiting and diarrhea, which are common symptoms of acute gastroenteritis. Dehydration can cause symptoms such as dry mucous membranes, tachycardia, hypotension, and oliguria. It can also lead to complications such as shock or kidney failure, which are serious but not as urgent as hypokalemia.
Choice D: Weight loss of 3% of total body weight. This is not the priority data collection finding that the nurse should identify for a client who has acute gastroenteritis. Weight loss of 3% of total body weight indicates mild to moderate dehydration, which can be caused by fluid loss from vomiting and diarrhea. Weight loss can also reflect loss of muscle mass or fat tissue due to malnutrition or inflammation. Weight loss can affect the client’s nutritional status and immune function, but it is not as urgent as hypokalemia.
A nurse is contributing to the plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse recommend for inclusion in the plan of care?
A. Increase the client’s sodium intake.
Choice A: Increase the client’s sodium intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Increasing the client’s sodium intake can worsen fluid retention and exacerbate ascites. The nurse should recommend limiting the client’s sodium intake to less than 2 g per day.
B. Decrease the client’s fluid intake.
Choice B: Decrease the client’s fluid intake. This is an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Cirrhosis is a chronic liver disease that causes scarring and impaired liver function. Ascites is a complication of cirrhosis that involves accumulation of fluid in the peritoneal cavity. Decreasing the client’s fluid intake can help reduce fluid retention and prevent further distension of the abdomen and pressure on the diaphragm.
C. Increase the client’s saturated fat intake.
Choice C: Increase the client’s saturated fat intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Increasing the client’s saturated fat intake can increase the risk of cardiovascular disease, obesity, and faty liver disease. The nurse should recommend a balanced diet that provides adequate protein, calories, vitamins, and minerals.
D. Decrease the client’s carbohydrate intake
Choice D: Decrease the client’s carbohydrate intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Decreasing the client’s carbohydrate intake can cause ketosis, which is a metabolic state that occurs when the body uses fat as a fuel source instead of glucose. Ketosis can cause nausea, fatigue, headache, and bad breath. The nurse should recommend a moderate carbohydrate intake that provides enough glucose for energy and prevents ketosis.
Full Explanation
Choice A: Increase the client’s sodium intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Increasing the client’s sodium intake can worsen fluid retention and exacerbate ascites. The nurse should recommend limiting the client’s sodium intake to less than 2 g per day.
Choice B: Decrease the client’s fluid intake. This is an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Cirrhosis is a chronic liver disease that causes scarring and impaired liver function. Ascites is a complication of cirrhosis that involves the accumulation of fluid in the peritoneal cavity. Decreasing the client’s fluid intake can help reduce fluid retention and prevent further distension of the abdomen and pressure on the diaphragm.
Choice C: Increase the client’s saturated fat intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Increasing the client’s saturated fat intake can increase the risk of cardiovascular disease, obesity, and faty liver disease. The nurse should recommend a balanced diet that provides adequate protein, calories, vitamins, and minerals.
Choice D: Decrease the client’s carbohydrate intake. This is not an intervention that the nurse should recommend for inclusion in the plan of care for a client who has cirrhosis and ascites. Decreasing the client’s carbohydrate intake can cause ketosis, which is a metabolic state that occurs when the body uses fat as a fuel source instead of glucose.
Ketosis can cause nausea, fatigue, headache, and bad breath. The nurse should recommend a moderate carbohydrate intake that provides enough glucose for energy and prevents ketosis.
A nurse is assisting with the plan of care for a client who has hypothyroidism with myxedema. Which of the following interventions should the nurse include in the plan of care?
A. Place the client on bedrest.
Choice A: Place the client on bedrest. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Placing the client on bedrest can increase the risk of complications such as thromboembolism, pressure ulcers, and muscle atrophy. The nurse should encourage the client to perform gentle exercises and change positions frequently.
B. Apply warm blankets.
Choice B: Apply warm blankets. This is an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Hypothyroidism is a condition that occurs when the thyroid gland does not produce enough thyroid hormone. Thyroid hormone regulates the metabolism of carbohydrates, proteins, and fats, and affects the energy expenditure and body temperature. Myxedema is a severe form of hypothyroidism that causes swelling of the skin and tissues due to accumulation of mucopolysaccharides. Applying warm blankets can help maintain the client’s body temperature and prevent hypothermia, which is a low body temperature.
C. Check the client for weight loss.
Choice C: Check the client for weight loss. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Checking the client for weight loss can indicate hyperthyroidism, which is a condition that occurs when the thyroid gland produces too much thyroid hormone. Hyperthyroidism can cause weight loss due to increased metabolic rate and appetite. The nurse should check the client for weight gain, which can indicate hypothyroidism due to decreased metabolic rate and fluid retention.
D. Limit high-fiber foods.
Choice D: Limit high-fiber foods. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Limiting high-fiber foods can cause constipation, which can worsen hypothyroidism symptoms such as bloating, abdominal pain, and fatigue. The nurse should encourage the client to eat high-fiber foods, such as fruits, vegetables, and whole grains, to promote bowel regularity and prevent constipation.
Full Explanation
Choice A: Place the client on bedrest. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Placing the client on bedrest can increase the risk of complications such as thromboembolism, pressure ulcers, and muscle atrophy. The nurse should encourage the client to perform gentle exercises and change positions frequently.
Choice B: Apply warm blankets. This is an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Hypothyroidism is a condition that occurs when the thyroid gland does not produce enough thyroid hormone. Thyroid hormone regulates the metabolism of carbohydrates, proteins, and fats, and affects the energy expenditure and body temperature. Myxedema is a severe form of hypothyroidism that causes swelling of the skin and tissues due to accumulation of mucopolysaccharides. Applying warm blankets can help maintain the client’s body temperature and prevent hypothermia, which is a low body temperature.
Choice C: Check the client for weight loss. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Checking the client for weight loss can indicate hyperthyroidism, which is a condition that occurs when the thyroid gland produces too much thyroid hormone.
Hyperthyroidism can cause weight loss due to increased metabolic rate and appetite. The nurse should check the client for weight gain, which can indicate hypothyroidism due to decreased metabolic rate and fluid retention.
Choice D: Limit high-fiber foods. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Limiting high-fiber foods can cause constipation, which can worsen hypothyroidism symptoms such as bloating, abdominal pain, and fatigue. The nurse should encourage the client to eat high-fiber foods, such as fruits, vegetables, and whole grains, to promote bowel regularity and prevent constipation.