Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following symptoms should a nurse expect to find when assessing an infant who is dehydrated in an emergency department? Select all that apply
A. Tachycardia.
“Tachycardia” and “Irritability” are both symptoms that a nurse should expect to find when assessing an infant who is dehydrated in an emergency department. Dehydration occurs when an infant loses so much body fluid that they are not able to maintain ordinary function. Tachycardia, or a fast heart rate, is a common sign of dehydration in babies and toddlers. Irritability is also a common sign of dehydration in newborns.
B. Bloating.
Choice B is not an answer because bloating is not a common symptom of dehydration in infants.
C. Hypertension.
Choice C is not an answer because hypertension, or high blood pressure, is not a common symptom of dehydration in infants.
D. Irritability.
Irritability is asymptomthat a nurse should expect to find when assessing an infant who is dehydrated in an emergency department.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Adult Med Surg 2020 with NGN Proctored Exam. Take the full exam now
Full Explanation
The correct answer is Choice A, Choice D.
Choice A rationale: Tachycardia, or an increased heart rate, is a common symptom of dehydration in infants. The body attempts to maintain adequate blood circulation despite reduced fluid volume by increasing the heart rate, which is a compensatory mechanism.
Choice B rationale: Bloating is not typically associated with dehydration in infants. Dehydration usually results in symptoms like dry mucous membranes and decreased skin turgor, rather than gastrointestinal symptoms like bloating.
Choice C rationale: Hypertension, or high blood pressure, is uncommon in dehydrated infants. Dehydration generally leads to hypotension (low blood pressure) due to decreased fluid volume in the circulatory system, which can result in reduced blood pressure.
Choice D rationale: Irritability is a frequent symptom of dehydration in infants. Reduced fluid intake and electrolyte imbalances can cause discomfort and distress, leading to irritability and increased fussiness in dehydrated infants.
Similar Questions
A nurse is collecting admission history data from a client who is in a semi-private room. Which of the following data is the priority for the nurse to address?
A. Recent exposure to tuberculosis
Recent exposure to tuberculosis. This is the priority data that the nurse should address as it puts other clients and hospital staff at risk of contracting tuberculosis
B. History of generalized anxiety disorder
This is not urgent and can be addressed after addressing option A. History of generalized anxiety disorder is not an urgent issue that requires the nurse's immediate attention
C. Reports periodic migraine headaches
This is not urgent and can be addressed after addressing option A. Reports periodic migraine headaches are not an urgent issue that requires the nurse's immediate attention.
D. Experiences nocturia
This is not urgent and can be addressed after addressing option A. Experiencing nocturia isnot an urgent issue that requires the nurse's immediate attention.
E. Experiences nocturia
Full Explanation
Recent exposure to tuberculosis. This is the priority data that the nurse should address as it puts other clients and hospital staff at risk of contracting tuberculosis. Options B, C, and D are not urgent and can be addressed after addressing option A.
Reasons why the other options are not answers:
Option B: A history of generalized anxiety disorder is not an urgent issue that requires the nurse's immediate attention.
Option C: Reports periodic migraine headaches are not an urgent issue that requires the nurse's immediate attention.
Option D: Experiencing nocturia is not an urgent issue that requires the nurse's immediate attention.
A nurse is collecting data from a female client during an initial health assessment. Which of the following findings should the nurse identify as a risk factor for osteoporosis?
A. Applies an estrogen vaginal cream daily
Estrogen is important for maintaining bone health, and a decrease in estrogen levels after menopause is a risk factor for osteoporosis. Using estrogen vaginal cream can indicate that the client is postmenopausal and may have a decreased level of estrogen, which puts her at risk for osteoporosis. Canned sardines are a good source of calcium, walking is good for overall health, and a beclomethasone inhaler is used for respiratory issues and does not affect bone health.
B. Includes canned sardines in her diet
Canned sardines are actually a good source of calcium, which is important for bone health.
C. Walks 30 min per day
Walking 30 minutes per day is a weight-bearing exercise that helps maintain bone density and is beneficial for preventing osteoporosis.
D. Uses a beclomethasone inhaler
Using a beclomethasone inhaler (a corticosteroid) can be a risk factor for osteoporosis, especially if used long-term, as corticosteroids can lead to bone loss.
Full Explanation
Choice A rationale: Applying an estrogen vaginal cream daily is not a risk factor for osteoporosis. In fact, estrogen can help maintain bone density.
Choice B rationale: Including canned sardines in the diet provides calcium and vitamin D, which are beneficial for bone health.
Choice C rationale: Walking 30 minutes per day is a weight-bearing exercise that helps maintain bone density and is beneficial for preventing osteoporosis.
Choice D rationale: Using a beclomethasone inhaler (a corticosteroid) can be a risk factor for osteoporosis, especially if used long-term, as corticosteroids can lead to bone loss.
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?
A. Temperature 37.3° C (99.1° F)
A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.
B. WBC Count 9,000/mm3
A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.
C. Changed mental status
A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.
D. Diminished reflexes
Diminished reflexes are not typically associated with a bladder infection.
Full Explanation
A bladder infection can lead to confusion or other changes in mental status, especially in older adults. A normal temperature and WBC count do not necessarily indicate a bladder infection. Diminished reflexes are not typically associated with a bladder infection.
A: A temperature of 37.3° C (99.1° F) is within the normal range and does not necessarily indicate a bladder infection.
B: A WBC count of 9,000/mm3 is within the normal range and does not necessarily indicate a bladder infection.
D: Diminished reflexes are not typically associated with a bladder infection.