Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which thermoregulatory condition is an elderly person most at risk for?
A. Hypothermia.
Hypothermia is a condition where the body temperature drops below 35°C (95°F) and affects the normal functioning of the body. Elderly people are more at risk for hypothermia because they have a lower muscle mass, a decreased
B. Normothermia.
Normothermia is wrong because it means having a normal body temperature, which is around 37°C (98.6°F).
C. Hyperthermia.
Hyperthermia is wrong because it means having a high body temperature, which is above 37.5°C (99.5°F). Hyperthermia can be caused by heat exposure, infection, inflammation, or certain medications.
D. Malignant hyperthermia.
Malignanthyperthermia is wrong because it is a rare genetic disorder that causes a severe reaction to certain anesthetics or muscle relaxants. It is not related to thermoregulation in elderly people.
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Full Explanation
Hypothermia is a condition where the body temperature drops below 35°C (95°F) and affects the normal functioning of the body. Elderly people are more at risk for hypothermia because they have a lower muscle mass, a decreased
shiver reflex, and lower immunity. They also tend to have a lower body temperature and may not develop fevers when they contract a viral or bacterial illness.
Choice B. Normothermia is wrong because it means having a normal body temperature, which is around 37°C (98.6°F).
Choice C. Hyperthermia is wrong because it means having a high body temperature, which is above 37.5°C (99.5°F).
Hyperthermia can be caused by heat exposure, infection, inflammation, or certain medications.
Choice D. Malignant hyperthermia is wrong because it is a rare genetic disorder that causes a severe reaction to certain anesthetics or muscle relaxants.
It is not related to thermoregulation in elderly people.
Question 5.
Similar Questions
A client has a history of gastric bypass surgery within the past year. She presents to her primary care office for a check-up and states she has been troubled by several seemingly unrelated ailments: a sore tongue, tingling in her fingers, and “almost” falling several times due to lack of balance. The nurse notes that she is pale and slightly tachycardic.
Which type of anemia does the nurse suspect?
A. Folic acid deficiency anemia.
Choice A is wrong because folic acid deficiency anemia is caused by the lack of folic acid in the diet or increased demand for folic acid, such as during pregnancy. Folic acid is also needed for red blood cell production, but it does not cause nerve symptoms.
B. Aplastic anemia.
Choice B is wrong because aplastic anemia is caused by the failure of the bone marrow to produce enough blood cells. It is not related to gastric bypass surgery or nutrient deficiency. It can be caused by infections, drugs, radiation, or autoimmune diseases.
C. Vitamin B12 deficiency anemia.
This type of anemia is caused by the reduced absorption of vitamin B12 in the small intestine after gastric bypass surgery. Vitamin B12 is needed for the production of healthy red blood cells and nerve function. The symptoms of vitamin B12 deficiency anemia include sore tongue, tingling in the fingers, and balance problems.
D. Acquired anemia.
Choice D is wrong because acquired anemia is a general term for any type of anemia that is not inherited or present at birth. It can have many causes, such as blood loss, infection, inflammation, or chronic disease. It does not specify the type of anemia or the underlying mechanism. Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women. Normal ranges for vitamin B12 are 200 to 900 pg/mL.
Full Explanation
This type of anemia is caused by the reduced absorption of vitamin B12 in the small intestine after gastric bypass surgery. Vitamin B12 is needed for the production of healthy red blood cells and nerve function. The symptoms of vitamin B12 deficiency anemia include sore tongue, tingling in the fingers, and balance problems.
Choice A is wrong because folic acid deficiency anemia is caused by the lack of folic acid in the diet or increased demand for folic acid, such as during pregnancy.
Folic acid is also needed for red blood cell production, but it does not cause nerve symptoms.
Choice B is wrong because aplastic anemia is caused by the failure of the bone marrow to produce enough blood cells.
It is not related to gastric bypass surgery or nutrient deficiency. It can be caused by infections, drugs, radiation, or autoimmune diseases.
Choice D is wrong because acquired anemia is a general term for any type of anemia that is not inherited or present at birth.
It can have many causes, such as blood loss, infection, inflammation, or chronic disease.
It does not specify the type of anemia or the underlying mechanism. Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women. Normal ranges for vitamin B12 are 200 to 900 pg/mL.
The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?
A. Patient will exhibit O2 saturation > 92% by discharge.
Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge. The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.
B. Teach pursed-lip breathing prior to discharge.
Choice B is wrong because it is not a goal statement, but an intervention. A goal statement should describe the expected outcome of the intervention, not the intervention itself.
C. Patient will state 2 ways to decrease chance of reinfection by the end of shift.
This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.
D. Patient will demonstrate pursed-lip breathing.
Choice D is wrong because it is not measurable or time-bound. A goal statement should have a clear indicator of how and when the outcome will be achieved.
Full Explanation
This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.
Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.
The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.
Choice B is wrong because it is not a goal statement, but an intervention.
A goal statement should describe the expected outcome of the intervention, not the intervention itself.
Choice D is wrong because it is not measurable or time-bound.
A goal statement should have a clear indicator of how and when the outcome will be achieved.
The RN performs an admission assessment and determines the client is a fall risk. What is a priority nursing intervention for this client?
A. Provide a walker.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
B. Place a chair on either side of the bed.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
C. Provide a cane.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.
D. Place a fall risk wrist band on the client.
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Full Explanation
This is because a fall risk wristband alerts the staff and other caregivers that the client is at risk of falling and needs extra precautions and supervision. A walker, a cane, or a chair on either side of the bed are not priority interventions for a fall risk client, as they do not address the root cause of the problem or prevent potential falls.
Choice A is wrong because a walker may not be appropriate for the client’s condition or mobility level, and it may pose a tripping hazard if not used correctly.
Choice B is wrong because placing a chair on either side of the bed may limit the client’s access to the bed or the bathroom, and it may also create clutter and obstruction in the room.
Choice C is wrong because a cane may not provide enough stability or support for the client, and it may also be difficult to use in narrow spaces or on slippery surfaces.