an 85 year old client is diagnosed with hypernatremia due to lack of fluid intake and dehydration the nurse knows that symptoms of hypernatremia incl

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. An 85-year-old client is diagnosed with hypernatremia due to lack of fluid intake and dehydration. The nurse knows that symptoms of hypernatremia include:

A. Lack of thirst
B. Pale skin
C. Hypertension
D. Swollen tongue

Correct answer: D

Rationale: Hypernatremia among elderly clients can result from dehydration and insufficient fluid intake, leading to sodium levels above 145 mEq/L. Common symptoms of hypernatremia include mental status changes, a thick or swollen tongue, excessive thirst, and flushed skin. Choice A, 'Lack of thirst,' is incorrect as hypernatremia typically presents with excessive thirst. Choice B, 'Pale skin,' is not a typical symptom of hypernatremia. Choice C, 'Hypertension,' is not a direct symptom of hypernatremia and is more commonly associated with other conditions like hypertension itself.

2. The healthcare professional in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the healthcare professional finds that the patient's blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the PRIORITY intervention?

A. Start a large-bore IV in the patient's arm
B. Ask the patient for a stool sample
C. Prepare to insert an NG Tube
D. Administer intramuscular morphine sulfate as ordered

Correct answer: A

Rationale: The priority intervention in this scenario is to start a large-bore IV in the patient's arm. The patient's low blood pressure (95/60) and elevated pulse rate (110 beats per minute) indicate a potential hemorrhage, requiring immediate fluid resuscitation. Starting a large-bore IV will allow for rapid administration of fluids to stabilize the patient's condition. Asking for a stool sample, preparing to insert an NG tube, or administering morphine sulfate should not take precedence over addressing the hemodynamic instability and potential hemorrhage observed in the patient. These actions may be considered later in the patient's care, but the primary focus should be on addressing the critical issue of fluid replacement and stabilization.

3. Which clinical manifestations are recognized in nephrotic syndrome?

A. Hematuria, bacteriuria, weight gain
B. Gross hematuria, albuminuria, fever
C. Hypertension, weight loss, proteinuria
D. Massive proteinuria, hypoalbuminemia, edema

Correct answer: D

Rationale: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema. In this syndrome, there is loss of proteins, particularly albumin, in the urine leading to hypoalbuminemia, fluid retention, and subsequent edema. This results in elevated lipid levels like hypercholesterolemia, but not hypertension. Therefore, choices A, B, and C are incorrect. Hematuria, bacteriuria, fever, and weight loss are not typically associated with nephrotic syndrome, distinguishing it from other kidney disorders.

4. A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to

A. A cerebral vascular accident
B. Postoperative meningitis
C. Medication reaction
D. Metabolic alkalosis

Correct answer: A

Rationale: The correct answer is a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, including cerebrovascular accidents. Signs and symptoms of a cerebral vascular accident include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures. Postoperative meningitis (choice B) is less likely in this scenario as the sudden onset of seizing is more indicative of a vascular event rather than an infection. Medication reaction (choice C) is not the most probable cause given the history provided. Metabolic alkalosis (choice D) is not associated with sudden seizing in this context.

5. A pregnant woman who is 36 weeks' pregnant and has hepatitis B is being informed by a nurse. Which of the following statements from the client indicates understanding of this condition?

A. Now I know my baby will need a cesarean section.
B. My baby will need two shots soon after birth.
C. I will not be able to breastfeed.
D. My baby's father does not need testing; I know I am the one with hepatitis.

Correct answer: B

Rationale: The correct answer is 'My baby will need two shots soon after birth.' A baby born to a mother with hepatitis B should receive two injections soon after birth to reduce the risk of contracting the disease. Within the first 12 hours post-birth, the baby should receive the first hepatitis B vaccine and hepatitis B immune globulin (HBIG) for additional protection. Option A is incorrect because the need for a cesarean section is not directly related to the mother's hepatitis B status. Option C is incorrect as breastfeeding can be safe if managed properly. Option D is incorrect as the baby's father should also be tested for hepatitis B to prevent transmission to the newborn.