Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse working in the PACU (post-anesthesia care unit)/recovery room unit is monitoring a patient whose vital signs were stable upon arrival from the operating room. The patient’s temperature began to rise steadily the past 20 minutes and continues to rise, the heart monitor shows sinus tachycardia with a rate of 122, the patient’s blood pressure is 86/42, and pulse ox is 88% on 2 L O2 via nasal cannula.
The nurse suspects which genetic condition?
A. Alpha-1 antitrypsin deficiency.
Choice A is wrong because alpha-1 antitrypsin deficiency is a genetic disorder that affects the lungs and liver, causing shortness of breath, wheezing, and jaundice. It does not cause a rise in body temperature or muscle rigidity.
B. Malignant hypothermia.
Choice B is wrong because malignant hypothermia does not exist. It is a misspelling of malignant hyperthermia.
C. Thalassemia.
Choice C is wrong because thalassemia is a genetic disorder that affects the production of hemoglobin, causing anemia, fatigue, and bone deformities. It does not cause a rise in body temperature or muscle rigidity.
D. Malignant hyperthermia.
Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia that can cause muscle rigidity, fever, and a fast heart rate. It can be fatal if not treated promptly with medication, oxygen, body cooling, and supportive care. The patient’s symptoms match those of malignant hyperthermia.
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
Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia that can cause muscle rigidity, fever, and a fast heart rate. It can be fatal if not treated promptly with medication, oxygen, body cooling, and supportive care. The patient’s symptoms match those of malignant hyperthermia.
Choice A is wrong because alpha-1 antitrypsin deficiency is a genetic disorder that affects the lungs and liver, causing shortness of breath, wheezing, and jaundice.
It does not cause a rise in body temperature or muscle rigidity. Choice B is wrong because malignant hypothermia does not exist. It is a misspelling of malignant hyperthermia.
Choice C is wrong because thalassemia is a genetic disorder that affects the production of hemoglobin, causing anemia, fatigue, and bone deformities.
It does not cause a rise in body temperature or muscle rigidity.
Similar Questions
A client who is at risk for developing osteoporosis asks what can be done to decrease the risk of actually developing the disorder.
Which intervention would be the most beneficial for this client?
A. Protecting the client’s bones with strict bedrest.
Choice A is wrong because protecting the client’s bones with strict bedrest can actually increase the risk of osteoporosis by reducing bone density and muscle mass. Bedrest should be avoided unless medically necessary.
B. Providing the client with assisted range of motion exercises twice daily.
Choice B is wrong because providing the client with assisted range of motion exercises twice daily is not enough to prevent osteoporosis. While these exercises can help maintain joint mobility and flexibility, they are not weight bearing and do not stimulate bone formation.
C. Decreasing the amount of calcium in the client’s diet.
Choice C is wrong because decreasing the amount of calcium in the client’s diet can also increase the risk of osteoporosis. Calcium is an essential mineral for bone health and adults need 700mg a day, which can be obtained from foods such as dairy products, leafy green vegetables, tofu, and dried fruit. Vitamin D is also important for bone health as it helps the body absorb calcium.
D. Increasing regular weight-bearing activities.
Increasing regular weight-bearing activities can help prevent osteoporosis by stimulating bone formation and improving muscle strength. Weight-bearing activities are those that make your bones and muscles work against gravity, such as walking, jogging, dancing, or lifting weights.
Full Explanation
Increasing regular weight-bearing activities can help prevent osteoporosis by stimulating bone formation and improving muscle strength. Weight-bearing activities are those that make your bones and muscles work against gravity, such as walking, jogging, dancing, or lifting weights.
Choice A is wrong because protecting the client’s bones with strict bedrest can actually increase the risk of osteoporosis by reducing bone density and muscle mass. Bedrest should be avoided unless medically necessary.
Choice B is wrong because providing the client with assisted range of motion exercises twice daily is not enough to prevent osteoporosis. While these exercises can help maintain joint mobility and flexibility, they are not weight bearing and do not stimulate bone formation.
Choice C is wrong because decreasing the amount of calcium in the client’s diet can also increase the risk of osteoporosis. Calcium is an essential mineral for bone health and adults need 700mg a day, which can be obtained from foods such as dairy products, leafy green vegetables, tofu, and dried fruit. Vitamin D is also important for bone health as it helps the body absorb calcium.
An elderly client is admitted to the hospital looking unkempt, with dirty clothing, and she smells of urine.
The nurse is aware this may be:
A. Institutionalism.
Choice A is wrong because institutionalism is not a type of elder abuse but a term that describes the loss of individuality and autonomy that can occur in institutional settings such as nursing homes.
B. Neglect.
Neglect refers to the refusal or failure to provide an elderly person with necessary care, such as food, water, shelter, personal hygiene, medicine, and other essentials of daily living. Signs and symptoms of neglect in elders can include: dehydration, malnutrition, bed sores, fractures, urinary tract infections, contractures, over-medication, elopements, and poor personal hygiene. An elderly client who is admitted to the hospital looking unkempt, with dirty clothing, and smelling of urine may be suffering from neglect by a caregiver or by themselves (self-neglect).
C. Emotional abuse.
Choice C is wrong because emotional abuse is the infliction of mental or emotional anguish by threat, humiliation, intimidation, or other abusive conduct. Signs and symptoms of emotional abuse in elders can include: depression, confusion, withdrawal, isolation from friends and family. An elderly client who smells of urine may not necessarily be emotionally abused.
D. Stubborn behavior.
Choice D is wrong because stubborn behavior is not a type of elder abuse but a personality trait that may or may not be present in an elderly person. Stubborn behavior does not indicate any harm or neglect inflicted upon an older adult by others or themselves.
Full Explanation
Neglect refers to the refusal or failure to provide an elderly person with necessary care, such as food, water, shelter, personal hygiene, medicine, and other essentials of daily living. Signs and symptoms of neglect in elders can include: dehydration, malnutrition, bed sores, fractures, urinary tract infections, contractures, over-medication, elopements, and poor personal hygiene. An elderly client who is admitted to the hospital looking unkempt, with dirty clothing, and smelling of urine may be suffering from neglect by a caregiver or by themselves (self-neglect).
Choice A is wrong because institutionalism is not a type of elder abuse but a term that describes the loss of individuality and autonomy that can occur in institutional settings such as nursing homes.
Choice C is wrong because emotional abuse is the infliction of mental or emotional anguish by threat, humiliation, intimidation, or other abusive conduct. Signs and symptoms of emotional abuse in elders can include: depression, confusion, withdrawal, isolation from friends and family. An elderly client who smells of urine may not necessarily be emotionally abused.
Choice D is wrong because stubborn behavior is not a type of elder abuse but a personality trait that may or may not be present in an elderly person.
Stubborn behavior does not indicate any harm or neglect inflicted upon an older adult by others or themselves.
The nurse graduate is reviewing his scope of practice.
Which of the following does he correctly identify as outlining the legal scope of practice for nursing?
A. Nurse Practice Act.
The Nurse Practice Act is a law that outlines the legal scope of practice for nursing in each state. It defines the roles, functions, responsibilities and activities that a nurse is educated, competent and authorized to perform. The Nurse Practice Act also establishes the regulatory bodies that create and implement rules and regulations to protect the public.
B. Nursing process.
Nursing process is wrong because it is a systematic method of providing nursing care, not a legal document that defines the scope of practice.
C. Code of Ethics.
Code of Ethics is wrong because it is a set of principles that guide the moral and professional conduct of nurses, not a legal document that defines the scope of practice.
D. Facility policies and procedures.
Facilitypolicies and procedures are wrong because they are specific guidelines for each healthcare organization, not a legal document that defines the scope of practice.
Full Explanation
The Nurse Practice Act is a law that outlines the legal scope of practice for nursing in each state. It defines the roles, functions, responsibilities and activities that a nurse is educated, competent and authorized to perform. The Nurse Practice Act also establishes the regulatory bodies that create and implement rules and regulations to protect the public.
Choice B. Nursing process is wrong because it is a systematic method of providing nursing care, not a legal document that defines the scope of practice.
Choice C. Code of Ethics is wrong because it is a set of principles that guide the moral and professional conduct of nurses, not a legal document that defines the scope of practice.
Choice D. Facility policies and procedures are wrong because they are specific guidelines for each healthcare organization, not a legal document that defines the scope of practice.